P - 76278• REQIlEST FOR ELECTRICAL INSPECTION
1� 7 g 7� 5 2 8 � Minnesota Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
• ' , ('651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mrz.us
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--using tha back of the whfte copy'rf necessary - the work covered by this request:
E�LEL CMEF:GY SAIiER`5� SWI1"�H
�
IICATION, REMOTE CONTROL,
ITS OF LESS THAN 50 VOLTS
Device or Aoparatus na. $.50
Unit @
ADDITIONAL
er Fixture
Traffic Siqnal Standard
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circufts and Two Inspection Trips Each Dwelling Unit @$80
Additional Inspection Trips @ $20
Inves6aative Fee
total fee is $201 � `��° ��
I hereby certify thffi I inspected the electrical installaGon d�crib� herein on the dates s�ted:
1(�f28pM81VBI11G81'BfKJRBS fDyS �••,•,�•�•"��V�• �r.� s!��G
' te Bondin Ins 'on $20 0 � �
S el IfISp2CtfOn @$30 per HoUr o�iaminan�moNm oare
S al Ir�s 'on Q$.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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1 975285
��'p ,1UN 14 2007
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p��� Rough-in Inspection Required7 ❑Yes � No Inspection Other Than Rough-In: [�Ready Now ❑Will Call
!�'� ���Q� You must call the inspector when readyl Date Ready:
I certify that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Jqb Site Street Address City
b�c7 {�IE HUli�7 �+T FF:II}LE'fi f�li*I 55�.��
Township Section Renge Fire No. County
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OrmeNpccupant Plame Please Provide Two (2) Phone Numbers Including Area Code
�1CKERI�fiii�lha CATNEfiThIE A � � � �
Eleetrieal Utility Electrical Utility Address
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tractor / Company Neme Contractor License Number Master Electrician or Power Limfted Technlclan
Htlh! I ELEt� I RIC CUft.F'GfiA I IOh! �:�t ��7�88� LicenseNumber
Ma�7(ng Address (Contractor, Company or Owner Perfortning Installation)
�:�OC� TE��iITpf;ihrL FiQt�Dq SAII�l1' F'fi,ULq (�(�! 55114
AutfioriZed $Igneture (ConVactor or Owner Performing Installation) Please Provide Two (2) Phone Numbers Including Area Code
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