P - 79736('� � REQUEST FOR ELEC7RICAL INSPECTION
1� 3 9- V� U j v� Minnesota Board of Electricity -
�� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW ' REMODEL 0 ADDIT ON ❑ REPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
� , �G.i�So�- S�-'�%?��SBS
GENERAL FEES Outdoor Li htin Standard $1
SFRVICLS / P(1WFR SI IPPI IFS Traffic Siqnal Standard @$5
401
AIARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
� Each Svstem Device or Apparatus p$.50
to
Fee @ 9
up �0 10
over 10 I
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two InspecGon Trips Each Dwelling Unit @$80
uS PER UNIT TOTAL FEE
Per Unit (minimum total fee is $20) � �•�
@ $25 �wsu+er,v«eiris�croausEaar
I hereby certify that I inspected the electrical inst�la6on desaibed herein on Ne dates sfated:
HER ADDITIONAL FEES h✓L/ �—/a -e 3
( IIII I{ II{ I{ III II II{ II III II III I{ IN I{ III N� I�
13998406
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Request e: Roughin Inspection Required? Yes No Inspeclion Other Than RougMn: �Ready Now WNI Call
�,Q Q7j You must call the inspeclor when ready! Date Ready.
i certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby iequest inspection of tl�e electriqf woAc at:
Job Site Address (Stree� Box, or Route No.) Ciry Zip Code
1��� N .Tivr�l�rr �1 ��1o�P �'Vr�I�,V1 ��2
-z
Ene�gy Minnegasco
Cl� 5oL-I37�-f ( )
tor License Number Master Electrician a P
� I � l � License Number —
Phone (s)
coPr
EB-00001Mt4 8.1.2002