P - 783501-46'�-�56 7�
OCNEW ❑REMODEL ❑ADDITION 0 REF
TENI�ORARy
CIRCUITS OF LESS THAN 50 VOLTS
Units � $50 Per Unit
dditional Unit @ $25
I IIII Il lii II III II III II NI Ii lll II NI II �I �� I�
1 4 6 8 4 5 6 7
REQUEST FOR ELECTRICAL INSPECTION
Minnesota Board of Electricity _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-352g www.electricity.state.mn.us
� Describe -using the bxk of the white copy if necessary - the work covered by this request:
SERVICE
�o
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Cirouits and Two Inspection Tdps Each Dwelling Unit �$80
Addi6onal Inspection Trips $20
InvesGga(ive Fee
TOTALFEE
(minimum total fee is $20) � p 5��
TMIS FREA FOR Il/SpECTp21AE OKV
I hereby cer6y that I inspecOed y�e electrical insialla6on described herein on the daBes st�ed:
..�...w � �v �r nv i �v�nr�t i to wITHIN 12 MONTHS
�
�fa�
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Request Date: Roughin Inspection Required? ❑ Yes No ��
� pection Other Than Rough-In: ❑Ready Nov��VY�iI Call
_ _ You must call the inspector when ready! Date Ready:
I certify that I am tt�e C�L�ENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electriql work at:
Job Site Address (Street Bo� or Route No.) City ZiP Code
n1163_NORTON AVE NE FRIDLEY
P M J HOMES ( ) ( �
�wer Supplier . ��
XCEL ENERGY
ntrada / Company Name Contractor License Number Master Elec6ician or P�
WEST STAR ELECTR IC � INC . CA01 9 3 6 �cense Number
iiling Address (Cqntractor, Company pr p�yner performing Installation)
6 3 2 4 LAICELAND F�VE N BROOKLYN PARK MN 5 5 4 2 8
BACK OF VE C OF ELECTRICITV COPY
E&OOOOtA-14 8.1.2002