P - 77713REQUEST FOR ELECTRI �L�I �SP�,C,TJOJV ��
1�� 5�- 2 5 0 � Minnesota Board of Electricity G�(,Ipj '�°!J(o�s �-. �
_ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �'
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy if necessary - the work covered by this request:
�T 5 7�� - � / " �e r�c� t CE'rY-1 %Y14S� �C���rt �CD�-v. 57��/t�I
0 to 400
401 to 8
Above 8
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or A aratus $.50
ADDITIONS TO THE GENERAL F
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Units @$50 Per Unit
Each Additional Unit (� S25
it @ $.25 per Fi�ure
rigation Boom @ $4C
Home Park Lots (o� $
@ $.31 per Mile
TION MAY BE
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L8592501
Traffic Si nal Standard $5
Su lemental Fee $20
Transformers u to 10 KVA a$10
Transformers over 10 KVA a$ 20
Transformer I Power Su I for Si ns / OuGine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ection Tri s a$20
Investi ative Fee
Reins ection Fee a $20
TOTAL FEE � ,., _ ,
(minimum total fee is $20) ����
I hereby certify that I inspeded the elecVipl installatron desaibed herein on Ne dates stated: �
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zvx�eo � naa�oowen on.E
:TED IF NOT COMPLETED WITHIN 12 MONTHS
r.,_ ��._�;
Date: Rou h-in Ins
�/��/G� g peckion Required? ❑ Yes �o Inspec[ion Other Than Rough-In: 0 Ready Now (�Vill Call
/ / —
( Yau must call the inspector when ready! Date Ready:
I certify that I am the �L+ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
J S' erStreet Add C�
��n �i�� Si��' r,�lo � F' "
Township Section Range Fire No. Counry �
Name
� � s � c
Electrical
� Provitle Two (2) Phone Numbers I
��/ `�n�� � \ /
�mpany rvame � Gon dor License Number Master Electrician or Power Limited Tech
� License Number
� %l� �'�!C G/�7
s(Contractor, ompany or Owner Performing Instal 'on)
� �" 6��" � /L1� �� S31 �
natu Contr or or Own Perfo ' nsta tion) P�ease Pro 'de Two 2) Phone Numbers Including Area Ca
) ,�� ���? ( )
ON BACK OF YELLOW COPY � OARD OF ELECTRIGTV CoPV cnsnnn. e_�c o