P - 78213REQUEST FOR ELECTRICAL INSPECTION
1� 5 9 0- 2 31 � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Sai� Paul, Minnesota 55104
��5�� � (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
❑ NEW REMOD L C] ADDITIO ❑ REPAIR Describe -usinq the back of the white copy if neces - the worlc covered by this request:
�Y.J C���sd v� ''��v3-S 7 j - �".307
�M, COMMUNICATION, REMOTE CONTROL,
:UITS, CIRCUITS Of LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL F
iIFAMILY DWELLINGS (PER UNIn
3 to 12 Units @ y50 Per Unit
Each Addifional Unit @ $25
OTHER ADDITIONAL FEES
Ligh6ng Retrofit @ $.25 per Fi�ure
Center Pivot Irriaation Boom (aD S40 .. _
Su �lemental Fee $20
Trarisformers u to 10 KVA $10
Transfortners over 10 KVA $ 20
Transformer I Power Su I for Si ns I OuUine Li htin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$8(1
Additional Inspection Trips �1$20
Inves6gative Fee
Reinscection Fee � S20
(minimum total fee is $20) I p�d ��
iH15 MFA Fqi INSPECTOR USE WlY
I hereby cerEfy tlwt I inspected the ek�c6ical insfaY�on described herein on the dafes stated:
.. b "k
S ial Ins tion $.31 er Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
����) �����������������������i������ (����N� ��. ,� Il'�7
15902315
` � Y ��,�,�=� �,S'Cr'i
Request Date: � . r Rough-in Inspedion Required? ❑ Yes Inspection Other Than Rough-In: ❑Ready Now VNII Call
3 �� ""
, You must call the inspector when ready! Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby �equest inspection of the elecfical work at:
J�� ress (Street, �X or Rout? No•� � (� �� G� I► l�`�� �P J 5� v�
l�f� ,�
��
Name
1 r��
� ���
nterPoMt E�gy, in�
��,Y
L1�IF ��� � � .
:ontractor, ing InsW
' i.
�re �, o�,e� �ro�;
��
BACK OF COVY BOM
�i�0 �
no (2) Phone Number(s
-��6"7 � )
�cense rvumoer master tiecmGan or
O/ "'7�j� �cense Number
/ � �
ELECTRICITV COPY
EB-OOOOfA-1/ 8.1.2002