P - 762841 7"�� 517 �' REQUEST FOR ELECTRICAL INSPECTION -
� o Minnesota Board of Electriciry
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� , �651) 64z-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
A�be -using the back of the whfte copy ff necessary - the work covered by this request:
E��.CL EhiEf�G�' SAb'EC�°S S►,�TTCH
Fee
�
over
m�b ONE & TWO FAMILY DWELLINGS, EACH UNIT
�e $10 Includes the Service and/or Power Supply up to 500 Amperes, All
,TION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
OF LESS THAN 50 VOLTS Additional Ins ection Tri @$20
hce or Apparatus @$.50 Invesbpative Fee
Jnits @ $50 Per Unft
di6onal Unit @ $25
OTHER A�
Retrofit (iil $25 oer f
ier Hour
per Mile
MAY BE
I I� I�III II I� � IN � HI 0� II I� 11 I� II �I I�II)
: -�.79751?�3
toc�i fee �s $ioi I �9� G�
I inspected the electrical instelletion d�crib� herein on the datas stated: �
'_D IF NOT COMPLETED WITHIN 12'.
RECD JUN 14 200�'
03��7- c� �a��
6� Z� C� I
"'�"'' Rough-in Inspection Required7 ❑Yes ,❑ No Inspecdon Other Than Rough-In: ❑,Ready Now ❑Will Call
F �,
(a %�. �..�{� � You must call the inspector when ready! Date Ready:
I c�rhfy that I am the 1.7 LICENSED CONIRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Street Address C�y
1��8,� I�IE Ghlt11'l��GA �7' Ff;I�LE'� �1�! 554,:a�
�ou�:G�ozs uE�:��.r� +��zr�r:�r�!�- ( ) ( )
Electrical Utility ElecVical Utllity Address
YCEL Ei�IEF�G�
ConVeclor / Company Nama Contrac[or License Number Master Electrician or Power Limi[ed
License Number
HUhIT ELEGT�IC rORF�O�ATIOhI CA a0�8:�
AAgAing Acidress (Contractor, Company or Owner Performing Installa6on)
�:��Ct iEf�Rii�F:i�aL F�+JPI7, SAI�lT F'AULq I�ihl 551iL'�
Authatized Signature (Contractor or Owner Perform�ng Installahon) Please Provide Two (2) Phone Numbers Inciuding Area Code
�5:� ���—�9:11 � �
FNSTRUCTIOM$ ON CK OF YELLOW COPY BOARD OF ELECTRICITV COPV F0.l1Mf11 A_�F n a vrme