P - 78415p REQUEST FOR ELECTRICAL INSPECTION �
1� 4- 9 4� O� O � Minnesota Board of Electricity - :
1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104
(65 4 -0 S 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ❑ RE EL ❑ ADDITION ❑ PA q� c -usi the back f e white copy if n essary - the xrork covered by this request:
J 1 rli fr. � o� .,///l/L///�Ai ,
0 to 400 Am ere $25
401 to 800 Am ere $50
Above 800 Am ere $75
CIRCUITS I FEEDERS
0 to 200 Am re$5
Above 200 Am re $10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Inctudes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwellirg Unit �$80
(minimum total fee is $20) � Q�� � C
TMS �REA Fp21N5PECiIXi USE OfLY
I hereby cer6y that I inspected the electrical inst�la6on described herein on the dales st�ed:
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I certiiy tt�at I am the CENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical wak at:
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Poaver Supplier
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Auu,«ized S�g'�r{Geneaaor, c
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IN87RUC'AIiS BAC YELLOW
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pplier Address
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� � • Contractor License Number AAaster ElecVician or P
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Perfortning Installadon)
�rn any or Perfortning InstaNadon) Phone (s) �
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BOARD ELEC7RICRV COPY
EB-00001A-14 8.1.2002