P - 77540F l�l�n�
�
,
Minnesota Boa� of 6�tricity
,, � 1,. �821 Univef5it� Avenue SUlle S•j2� ���� P
,,,+,, ��, � aVl
��ti,��,����������� � M►,,
�;����.�,,,,��� ,
�
��, ��
�
�N��
���� �
�,,
�,
�U.Q QC��ICI�y.State.mn.us
Id2Allfy {he work covered by this request:
❑ iIE1N ❑ REMODEL �DDITION ❑ REPAIR G G [..,a,� �.t � �� �i�
r_ruco.� ���..
0 t0 400 Ampere � $25
401 to 800 Arnpere � $50
Above 800 Ampere f� $75
:UITS / FEEDERS
) to 200 Ampere � $5 � �C
4bove 200 Ampere � $10
�M, COMMUNICATION, REMOTE
UITS, CIRCUITS OF LESS THAI
:ach System Device or Apparatu�
ADDITIONS TO THE
�IFAMILY DWELLINGS (PER UN
to 12 Units �$Sp Per UnR
:ach Additanal Unit � $25
OTHER ADDITIC
ighting Retrofit � $.25 per Fixtur
eMer Pivot IrrigaHon Boom � $4
lanufactured Home Park Lots �
ecreatiorrel Vehide Pa�k Sites �
to 1i
�r 10
�—`"� i ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service ar�dlor Power Supply up to 500 qmperes, All
�ONTROL, SIGNALING Circuits and Two Inspection Trips Each pwelli Und �$8p
50 VOLTS Additional In ion Tri s�$20
�_ a•� Investigative Fee
FEES
total fee is
I inspected the electrical installati�on desqibed herein on the dates stated:
�' �� .. —�v� �
��iai ms on �$,31 � Mile o"'�
= THIS INSTALLATION MAY BE ORDERED DISCON C ED IF NOT COMPLETED WITHINI�B M NT S, o
FOR OFFlCE USE ONLY / �-
IIIIIIIIIIIIIIIIIIIIII -��_ bo��
IIIII IIIII IIIII III �
tl IIII IIII
� 1� 4 7 5 D 1 7�
Request Date: � Rough-in Inspection Required? ❑ Yes
�_� _ U� ❑ No Inspection O[her Than Rough-In: ❑ Ready Now � Will Call
You must call the inspector when ready! Date Ready:
� certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY
B'OWNER and hereby request inspection of the electrical wo�C at:
Job Address (Street, Box, or Route No.) �m,
5'� Y/ � zp �
� Po l. lc S-r (L1 pL - S5�-13 �
Section Township
Range Fire No. Coun
Occupant
3 � �' f� �o k Ot
n r' ' Phone
Power SuOppl� � '`� w � e�,e� � � � 7' —1 I �p !
eiac��cai c:oMractor / Company Name
_ � c..� N iz �2
Mailing Address (Contractor, Company or
� l� M �
Authonzed Signature (Contracror, Compar
wner Pertortning Installation)
Or OWf1er Pe1foRllifla Installa
Contractor License Number Master License
" '? � �3 5'7 ! `i l G 7
EB���A 13 �/��� BOARD OF ELECTqICITY COPY
�N�UCT�ONS ON BACK OF YELLOW CppY