P - 79748- REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity 4
1-396-560 � 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTYiMRS 1-800-627-3529
www. electricit y. sta te. mn. us
Identify the work covered by this request:
L] NEW ❑ REMODEL ❑ ADDITION ❑
800
Above 200 Am ere � $10
ALARM, COMMUNICATION, REMOTE CONTROL,
CIRCUITS. CIRCUITS OF LESS THAN 50 VOLTS
Each SVStem Device or Apparatus �$.50
3 to 12 Units �$50 Pe
Each Additional Unit �
Recreational
XCEL EMEROY SAVER'S SWITCH
ONE 8 N/O FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling UnR �$80
Additionai Insoection Trips � $20
FOR INSPECTOR USE ONLY
I hereby certNy that I inspecteE the elecl'icel
ROUGH IN
FINAL INSPECTION /
TOTAL FEE
total fee is $20)
on Me aetes smtetl:
DRTE
DATE
�•z7-�3
FOR OFFICE USE ONLY
I III�II I�II� �III III�I I�III .II�I �III �I�I �II (III �� �
* 1 3 9 6 5 6 0 3* �� �;S-v
Reque� ��roZ Rough-in Inspection Required? ❑ Yes �No Inspection Other Than Rough-in: �$Ready Now ❑ Will Call
You must call the inspector when ready( Date Ready:
I certiiy that I am the � LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Addres.���, eo�� �� c�ry F���, z�p coda �
SecNon Township Range Fire No. Counry
OccuYM11�A`! �1� Q PFwne
Power Suoolie[ �� Address
7�l
Electrical G.opVacWr, /,Cpqp���T'� Contractor Licposia Nu�aher. Master license Number
1"1�JIY 1 C.4C4 � RI �'1 W8C3
Mai�ing q��e���� � ��t� �tia�N 55114
Authorize ' nature (�t� om an or Owner Perfortning Installation) Phone �� Q,q��g11
EB-OOOOtA-13 711f2000 BOARD OF ELECTRICITY COPY INSTRUCTIONS ON BACK OF YELLOW COPY