P - 756872 0?� 113 � REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electriciry
��---e— -�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Descdbe -usir�g the back of the white copy if necessary - the work covered by this r�ua�t:
�l aC �7�ii �V.Tt�t t!s4 �- !l�2.Vl C �2 S
Above 800 Am�re @ $75 �
;UITS I FEEDERS
0 to 200 Ampere @ $5
Above 200 Ampere @$10
tM, COMMUNICATION, REMOTE CONTROL, SIGPIALING
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
3 to 12 Units �$50 Pe
Each Addi�onal Unit Q
OTHE
Lia►mrm rietrofit ro2 5.2:
Mile
\Y I
�II� �� ��I �� �� � ��� �� ��� �� ��� �� ��� �� ��� �� ��
�07[]1132
Fee
Includes the Service andlor Power Supply up to 500 Amperes, AII
Circuits and Two Inspecfion Trips Each Dwe�ing Unit @$80
TOTALFEE
total fee is $zo) � �- 5Z)
1 herebvi certHv fhet I fisoeded the electrical insfaVadon desa�bed herein on tlre dat� sfated: I
�. "
REC'��� ��� �E ��Y 3 2007
�����a`��
��� Rough-fi Inspactlon R�uiredl ❑ Yes � Inspectlon Other Than Rough-In: ❑ Ready No�,�tltl�'Ce0
�— o� You must cep the inspedor when readyl Date Ready.
I cerbfy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the elecfical wrork at
Job Site Street Address Cfly
1 �i rs � .�.� � � ��/-�.�,.
( )
.�-
( )
masmr rrecmaen or
Lice�e Number
�% ZZ Z C� ��
tred S g (Contrador or Owner Performirtg I n) Ple�e Provide Two (2) Phorre Numbeis I
(�'�- S�'�a-c� )
nae nu nere nc vc� � nw rnw Rll�Rll (1F FI FI`TRI(`RY (`lIOV