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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