P - 76984REQUEST FOR ELECTRICAL INSPECTION -
2���F� - 9�14 Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
• (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Desaibe �sing the back � tlie white copy'rf necessary - the cove by ihis request: , ,/� /
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I SERVICES / POWER SUPPLIES
Above 200 Am re S10 Includes the Service andlor Power Supply up to 500 Amperes, All
tM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspectbn Trips Each Dwellirg Unit (a� $80
UITS, CIRCUITS Of LESS THAN 50 VOLTS Additi�al ins ' Tri =20
Each Svstem Device w Aoaaratus Cd! $.50 Investipative Fee
TUTAL FEE �O , �O
t0�� fCE IS $ZU)
I I�erebvi cer6W U�at I insoeRed tlie electrirrl eretalla6on deacribed I�n on Cie de�es steEed:
CeMer Pivot Irtgation Boom @
ManuFadured Home Park Lots
THIS INSTALLATION MAY BE ORDERED D13CONNECTED IF NOT COMPLETED WITHMI 12 MONTHS
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�I����I�u�IIIIH��A�NN�II���I 4�CD .�UN 14 2007
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uare: RougMn InspecUon Required? ❑ Yes �No Inapection Olher Than Rough-Irr. � R�dy Now �4Vi� CaN
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�- ���� / You must call the inspedor when r�dy! Date Ready.
I certify that I am the � LICENSED CONTRACTOR � COMPANY ❑ OWNER and hereby request inspec6on of Hie electrical �1c at
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Township Section Range Fire No. County
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OwnerR3cwpeM Please Provide Two (2j Phone Numbers Inck�dinp Area Code
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Ele�i�l � / Eledrical llGlky Add^�
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Contredor / Company Name ConVactor Licenee Number Master E '' n or Power L'anited Technia
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MeiGng naeress (Cono-aaor, canpany or owner Pertorming Insmaabon)
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Autl�orited Owner Performing In P� Piovide Two (2) Phone Numbers Induding Area Code
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W3TR CK OF VELLOW COVY HtlARO OF FI FCTRICIN C(]PV FRfY1fIfMd15 A 1: