P - 78927�j �� REQUEST FOR ELECTRICAL INSPECTION
i� 6 4 7- 7 0 4�4 Minnesota Board of Electricity -
f" �1 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
CI�— � 1� (651) 642-0800 TfY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW REMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the while copy if necessary - ihe work covered b this request:
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GENERAL FEES Outdoor Li htin Standard $1
SERVICES / POWER SUPPLIES Traffi� Sianal SfanAarA (n1 QS
0 to 400 Ai
401 to 800
ALARM, GOMMUNICATION, REMOTE CONTROL,
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
3to12
Each A
:5 per Fixture
Boom � S40
Trarisformers u to 10 KVA $10
Tr�sformers over 10 KVA �$ 20
Tr�sformer / Power SupD�Y �r Signs / OuBine Lightina @ ES
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service andlor Power Supply up to 500 Amperes, All
Circuits and Txro Inspection Trips Each Dwelling Unit �$60
TOTAL FEE I �
(minimum total fee is $20) �6
T HIS qREA FOR N15PECTpt USE OKY
I hereby certify Mffi I inspected the elettrital insfak�on destnbed herein on Me da�es sf�eA:
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16477044
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Requ�t Date: R�wgh-in Inspection Required? Yes Np ��
�_ O� pedion Other Than Roughan: ❑Ready Pbw I Ca�l
p�a You must call fhe inspecta when ready! Date Ready
I certify ihat I am the �LICENSED CONTRACTOR 0 COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address iStBet �OX or Roub No.) City Zip Code
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�Qint Energy'
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'ower supp�ier Address
negasco
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IN87RUC710NS ON BAGK OF YELLOWZ(gpy ... BO ' O"r ELECTRIGTV COPY
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Please Rowde rwo (z) Pr,o�e rMn„eer(s� Mauang aea code
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nse Number Masta Electriaan a Power Limited Tedmician
� � � License Number
Phane (5)
EB•00001M70 8.1. T002