P - 77701REQUEST FOR ELECTRIC�L INSPECTION
1 61 �� O�� � Minnesota Board of Electricity �Q��- Q a�3� -
1821 University Avenue Suite S-128, SaiM Paul, innesota 04
� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
O NEW ❑ REMODEL ❑ ADDITIgN EPAIR Describe -using the back of the white copy if necessary - the work covered by this request:
/1°�_ ��B�tii�J' �> � t�iQ,�' d���,1k.�L�Be� � �i� .
SERVICES I
ALARM, GOMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or alus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @ y50 Per Unit
Each Addifional Unit � E25
� Retrofit � 5.25 per Fixture
Pivot Irtigation Boom @ yW
ctured Hortie Partc Lots (aD E
tional Vehide Park Sites � ;
IIIII IIIII Ilill IIIII IIIII IIIII IIIII IIIII �III I��
16150385
Traffic Signal Standard
Suoolemental Fee � 8
Includes tl�e Service andlor Power Supply up to 500 Amperes, NI
CirouiL� and Two Inspection Trips Each Dweliing Unit @ S80
TOTALFEE
(minimum total fee is $20) �Qs �
THIS AREA Fpt R6PECip2 USE 011Y
I hereby cer6fy Mat I inspecmd the ekctrical insfalla6on described herein on the dates stffied:
`l� '
rtequest uate: Rough-in Inspec6ai Required? ❑ Yes �'fJO Inspedion Other Than Rough-In: ❑Ready Now B'`WI Call
� Z � tj� You must call Me inspeeta when ready! pe� �y:
I certify ihat I am tlie ICENSED CONTRACTOR ❑ CONPANY ❑ ONMER and hereby request inspe�tion of the electrical work at: