P - 76297� REQIJEST FOR ELECTRICAL INSPECTION
1��s7 �- 5 4 3� Minnesota Board of Electricity •�
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
• , (651) 642-0800 TTY/MRS 1-800-627-3529 www.elecri-icity.state.mn.us
Davcribe -using the back of the white copy if necessary - the work covered by this request
E��CEL Ei�EFiGY aAVE� °� St�ITCH
GENERAL FEES Outdoor Liahtina Standard (a $1
CIRCUITS OF LESS THAN 50 VOLTS
ADDITIONS TO THE GENERAL FEES
Boom
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer / Power Supply for Signs / Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Suppiy up to 500 Am�res, All
C(rcuits and Two Inspection Trips Each Dxrelling Unit @$80
TOTAL FEE I
(minimum total fee is $20) ��° �
THISAREA FOR WSPECTOR USE OM.Y
I herebv certifv that I insp�[etl the ei�trical instaVaGon described herein an the da0es smted:
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�ALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED IMTHIN 12 MONTHS ________�
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17975434
REC'D � UN 14 2001
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��� Rough-in Inspection Required7 ❑ Yes �] No Inspection Other Than Rough-In: [kReady Now �Will Call
'�� �. �. /�41� You must call the inspector when ready! Date Ready:
f cettify ttjat I arr� the I� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Straet Address �� F�' I�i L E'� 9 h1 i�i
531 �.I�E Cf;ECK �L+�D NE �„
Topmslvp Secdon Range Fire No. Cou
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Oym�r/OGCUpant Name Please Provide Two (2) Phone Numbere Including Area Code
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Elechical Utll'dy Electrlql Utlltty Address
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Contractor / Company Name Contrador License Number Mester Electricien or Power Limited Technician
("�U�'I ��CI_:fF,jC Cl��iF'd�tiFi��l]%) C�i fJ��$� LlcenseNumber
N}8iling Address (Contractor, Company or Ovmer Performing InsTallatlon)
; �u�r rEF:�:l�����a� r,�����q SAThlT ���u�q ;�r� G����
AuEhor6�ed SIg1�eaWre (ConVactor or Owner Performing Installation) Please Provlde Two (2) Phone Numbers Including Area Code
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