P - 76244REQUEST FOR ELECTRICAL INSPEC 10
' .���� � � � � 3 3 �� ��nnesota Board of Electricity �I D��
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1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
�' �651) 642-0800 TTY/MRS 1-80 - 9 www.eleciricity.state.mn.us
Descnbe -using the back aF the white mpy if cessary - the work cbvered by this request:
�I�/'��:?'/�C,a� f�1rL � LL1 L 1/!aP/�7 i
I SERVICES / POWER SUPPLIES
Above 2(1D Am ere $10
ALARM, CAMMUNICATION, REMOTE CONTROL, SIGI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each tem Device orA @ $.5U
ADDITIONS TO THE GENERAL FEES
to 12 Units C� $50 Per Unft
Pefk Lots
ONE � TWO FAMILY DWEWNGS, EACH UNR
Includes the Service andlor Power Supply up to 5U0 Amperes, Au
Circuits and Two InspecUon Tri� Each Dwellmg Unit @$80
i�irur , I �� �,`
total fee is $20 � t�
I hereby certlfythet I inspected fhe ele�icel irefaVaHnn desamed hereln on the dates steted: I
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THIS INSTALLATtON MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTH�
F�R OFFICE USE ONLY
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�' �j �/ Rough-in Inspedton Requir�T ❑Yes o I
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You must ca0 the inspedor when readyl Date Readr
I cerfdy that I am the CENSED COMRACTOR ❑ COMPANY ❑ OWNER arM hereby request i[�spection of the electrical wwk at
Job SMe Street Address
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Master El�tridan or Power
Licer�se Number
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