P - 76295� � I�EQUEST FOR ELECTRICAL INSPECTION
1�� 9 7- 5 4 5� Minnesota Board of Electricity
„ 1821 University Avenue Suite 5-128, Saint Paul. Minnesota 55104
. (b`51) 64S-O800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Qe9Gribe -using the back of the white copy ff necessary - the work covered by this request:
E�CEL EhlERGY S�i�rEFi'S. SWITCN
GENERAL FEES Outdoor Lighting Standard @$1
SERVIGES / PWVER SUPPLIES Traffic Siqnal Standard (�a. $5
IMMUNICATION, REMOTE CONTROL
CIRCUITS OF LESS THAN 50 VOLTS
tvstem Device or Aooaratus l� $.50
Unft @ $25
OTHER ADDITIONAL FEES
(a� $25 �r Fi�ure
Haur
Mile
4Y BE ORDERED
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Transformer I Power Su I for SI ns I OuUine Li htln $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Ciroufts and Two Inspection Trips Each Dwelling Unft @$80
Additlonal Ins ction Tri $20
Investlgative Fee
Reins ction Fee @ $20
TOTALFEE
(minimum total fee is $20) ��_ °��
THISAPEA FOR MSPECTOR USE OFRY
I hereby certify thal I inspected the el�tricel instellatlon described hereln on the dates st�ed:
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:TED IF NOT COMPLETED WITHIN 12 M
RECD JUN 14 2Q01
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tl1i' Rough-in Inspection Required? ❑Yes �] No Inspection Other Than Rough-In: �Ready Now �Will Call
6, �. �. i � I You must cxll the inspector when readyl Date Ready:
I certily that I am the �1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sqe Street Address
5�55 i�0i�lEDE Si hIE c�Ff,T�LEYq I�ha
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OLSEi'�lq �,�1Fi�;IhlIt=t C � � � �
EleeMcal UtiMy Elec6ipl UtilityAddress
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ContraCtOr / Compeny Name Contractor License Number Master Electrician or Power Umited "
HL{h!T ELEGTrIC CO�:F'OFit�TI0i�1 � A����� ucenseNumber
MaNing Address (COntractor, Company or Owner Performing Installation)
�3a�J iE�RTp�7F�I�L F:O�iU� SATh1T F'AUL9 I�I�! 5�11Q
AYthorfz� Stgnature (ConVactor ar Ovmer Performing Installation) Please Provide Two (2) Phone Numbers Including Area
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UIBTRUCTION& ON ACK OF YELLOW COPY BOARD OF EI FCTRICITV Cf1PVi ce nnm�. n. c