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P - 77602REQUEST FOR ELECTRICAL INSPECTION 1� 6 41- 916 � Minnesota Board of Electricity 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 (651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us ❑ MODEL ❑ AD ION ❑ REPAIR Describe -using the b of the white copy if necess�y - the work covered by this request: � � � ENERAL FEES Outdoor Li htin Standard $1 SERYICES / POWER SUPPLIES __,.- . /A Traffic Sional Standard (a� $5 {� 0 to 400 Am ere S25 401 to 800 Am ere $50 Above 800 Am ere E75 R IFEEDERS to 200 Am re $5 Above 200 Am e $10 ALARM, COMMUNICATION, REMOTE CONTROI CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Each Svstem Device or Aouaratus � 5.50 2 Units @ $50 Per Unit Additional Unit @ $25 S ecial Ins ec6on $30 er Hour Special Inspection � $.31 per Mile THIS INSTALLATION MAY BE ORD IIIII II III II III II O! Il lli ll lll ll lll ll lil ll� l�ll 1641916� Includes the Service andlor Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwelling Unit @$80 TOTALFEE I ��� (minimum total fee is $20) � iH15 AREA Fq21N5PECipi USE WlV I hereby ceNy Ih� I inspected the electricai installa6on described herein on the dates sfaled: �r� �� D DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS _ I � ���L � �05 - ��� � � rceques[ u e: Rough-in Inspeclion Required7 l!/Yes ❑ No Inspection Other Than Rough-In: ❑Ready Now 0'Will Call �� �� You must call the inspeda when ready! Date Ready: i cerMy ihat I am tt�e f�LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspec6on of the elecUical work at: J Site Addess (SUeet Box or Route No.) Zip Code y� ove���, fl� �;a�e� 55y3Z n rvame �. V i� �j n �� 1 VI ' LJ[... � �a �f,t1P.fAr , LY mamn9 lwr�accor, t:omPenY or l�ll � ���lF,,.E,�� ,�o�. Please Provide Two (2) Phane Number(s � 5'l 1 �U.�o � ) :ontraclor License Number Master FJectriaan ar P � � � � �` - License Number Y! �� � � 1L � �3 , �JCJ�'l 1la � Phane (5> — °r�JL,��1 � lDL eo�ao aF e�crnicm coPr EB-00007M14 8.1.2002 � __