P - 75934REQUEST FOR ELECTRICAL INSPECTION
��� 2�� 4, o� � Minnesota Board of`�lectrici�y
1821 Universify Avenue Suite 5-128, Saint Paul, MinneSOta 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the whfte copy'rf necagsary�lhe�rk covered by this r�uest:
i . . . � _ �
Above 800 Amper
;UITS / FEEDERS
0 to 200 Amoere (
CIRCUITS OF I.ESS THAN 50 VOLTS
ipstem Device or Apparetus � $.50
ADDITIONS TO THE GENERAL I
Cemer
�offi
ATION MAY BE ORDERED �
IIIIII�IIII4I�II�IIIIIIIIIIuWl�lll��l�11
18204065
Traffic Sianal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, M
Ciraiits and Two Inspection Trips Each Dwel nit (o� $80
Additional Ins 'on Tri $2�
Investi ative F�
Reins 'on Fe,e $20
TOTAL FEE , �D
(minimum total fee is $20) �
nosa�ar�u�croaus� r
I hereby ceAiyNat I inspect� tlre electri�l instellallon d on �Se'd�s st�.' �
aa�c++w .. unre �
� G-�
�` .� �..,�i�"�a�
IF PIOT
POR OFFICE USE ONLY
���`���
����¢
�� Rough-in Inspecdon R�ulr�'7 ❑Yes ❑No InspecHon OtherThan Rough-In: �Ready Now ❑WN Call
You must call the inspector when readyl Date Ready.
I certiify that I am the ❑ LICENSED CONTRAC�TOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical xrork at
Job Sfte StreetAddresa City
S I 3� 1--�►�o t"t�.oc� �tL. N� �r� ���,.�
� �l
�.r�/° riease rrwme � wo ��� r�rone nwnners mc�uauig rvea �.wi
ts� � f �— D � S� I � 1 �J ( [�� fWV °�J
Electrical UtilitYAddress
s 13g 1r�or���+ �r N �.�rt� �
� Co�rtrador Llcense Number MasOer Electridan or Povrer Limit� Techr
a°F(7 �� �i � � 1� Ucense Number
Cit�)57� °7r8� (��1��