P - 76968REQUEST FOR ELECTRICAL INSPECTION
I�� 8 2 0°� 28 5 Minnesota Board of Electricity
� � 1821 UniversRy Avenue Suite S-128, Saint Paul, Minnesota 55104
• • E�' (651)642-0800TTY/MRS1-800-627-3529www.electricity.state.mn.us
Describe -using fhe badc of the white copy 'rf necessary - the wak covered by this request:
�U►in a C� n P� � : �S � � � ��-g � �-e� �--
ao, to eoo
Above 800
1MMUNICATION, REMOTE CANTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS
iifAMILY DWELLINGS
3 to 12 UniGs Cc� $50 Per
ManuFadured Fbme
THIS INSTALLATION MAY BE ORDERED DISCONNE
� I���II��������IN�� �
18202�5 O
Transfamers rner 10 KVA S 20
Transfamer / Power Su for S' ns / OuGine L' fi $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 Q$80
Additional In ' Tri s $20 ap
Invesf tive Fee
Reins ' Fee 520
TOTALFEE
(minimum total fee is $20) l� sQ
n�su�nraewsr�crartusE v
I hereby certify ihat I ir�speded tlie elec4ical insfaNation desaibed hwein on tlie dates sfated:
nouc,�x� ( " ���'= /�'� V�
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IF NOT
REC'D J ��t„€� ���=��2001
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��' Rough-in Inspedion Required? �1(es ❑ No Inspec6on Other Than Rough-Irr. � Ready Now.�WiB Call
�Q��� You must call the inspector when ready! Date Ready:
I certily that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
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or
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Con6actor Lic�nae Number Master Electrician or
License Number