P - 761391 9 9� 0 2�� REQUEST FOR ELECTRICAL INSPECTION
� � Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.edeclricity.state.mn.us
Describe -using the back of the white co�rf n - the wrork covered bythis request•
�Q,DIIIGP_ S2Jf1/1 t� �iQ�111r�_ ��t�.T71/� !/IoGtS�.
iNl, COMMUNICATION, REMOTE CONTROL, SIGNALING
.UITS, CIRGUffS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDRIONS TO THE GENERAL FEES
fIFAMILY DWELLINGS (PER UNII�
3 to 12 Units Crd. $50 Per Unit
Park Lots (
Park Sites
FALLATION MAY BE ORDERED
I IUI �ul u ul II III �I III � III II IU u�I) �� I�
1991028�1
Outdoor Liahtirm Standard
Transformers over 10 KVA $ 20
Transformer / Power Su I for Si ns / OuUine Li hti $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNR
Includes the Service and/or Power Supply up to 500 Amperes, All Q
Circuifs and Two InspecUon Trips Each Dweuing Unft @$BO O�'��
�
TOTALFEE
to�i f� �S $zo� go.00
THIS AREA FOP W3�EtTOR USE OM.Y �`�
/�V
o��� �
d the electrical InstaVatlon dasaibed � n on tlre dates
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IF NOT COMPLETED VYfTHIN 92 MONTHS
� or< r�eF�c� u,� or,;i
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uatn. RoU h-in IIIS
/ g pection Requir�7 es ❑ No Inspecdon Other Than Rough-In: 0 Ready Now III Call
`�` ��Q v You must call the inspectar when readyl Date Ready.
I certify that I am the � LICENSED CONTRACTOR 0 COMPANY ❑ OWNER and hereby request inspection of the electricai work at
Job Site Street Addr�s C�y
56�3 �is 'rva� � Fr�i��eti
����P � secdon Range Fire Na. County
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OwnedOaa�parrt Name Please Provide Two (2) Phoire Numbeis Including Area Code
In�i �w►�r awts �-�� ` f1G� 5Z - 7( )
Electrical Utllity Electriwl Utllity Addr�s
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Co cror! Company Name Contrador Ucense N �r Master Electrician or Power Limfted Technidan
� ��i �i CR � "'j License Number D,
MaUmg dr�s Contrador, Company or Owner Performing Installatlon)
2�13 132t+d ne, � Cooh ids !J S�8'
Autho Signature (C ctor or Oamer Perfortning InsTaliatlon) Please Prodde Two (2) Phorre Numbe�s InGudin Area Code
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�TR ONS ON BACK OF YELLOW COPY BOARD OF ELECTRICIT' COPV FFtnImnlA-15 a 9 9nna