P - 75400' =�� REQUEST FOR ELECTRICAL INSPECTION �
`�:' �.4� �� 2 6 7 � Minnesota Board of Electricity
�' 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electrlcity.state.mn.us �� "��
Describe -using the back of tha whfte copy'd necessary - the work covered by this ra�uest:
�oV��(f � CANN�� Ltilr}�T3 A� M�N'� O�rl.��s �5 a��GCSS'bRi
GENERAL FEES Outdoor Liahtina Standard C� $1
0 to
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
.TIFAMILY
INSTALLATION MAY BE ORDERED C
,,.
Transformers up ta
Transformers wer
ONE & TWD FAMILY DYVELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Addi�onal Irus on Tri $20
Irn�stigative Fee
Reins 'on Fee $20
TOTAL FEE � .�^�
e� (minimum total fee is $20) � �
nus a�n wa wsPri,�az us� ow.
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I here�6y certlfyf� I i�pe�d the electrical on � herein on fhe dates ate�:
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iD IF NOT COMPLETED WITHIN 12 MON HS
�OP.OFFICEIJS 1 �V
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18202671 0�-7�%
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g spectlon RequhedT �Yes ❑ No Inspecllon Other Than Rough-In: � Ready Now�fO CaII
1" � Z'� ��� You must call the Uisp�tor when readyl Date Ready.
I c�rtiFy that I am the � LICENSED CQNTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electrical work at
Job Site Street Address Cgy
C3oa M0N(106 sr. ,� � �R ����.�
� ��FF R�,n,u�E�i.�R
� ��
or
('�63) �.58 -� y 9 36 ( ro � n
ise Number Master Eiectrician or Power LimPo
License Number
Please Provide Tvro (2) Phorre Numbers Including A
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