P - 77594REQUEST FOR ELECTRICAL INSPECTION ���`���
�� 8 4, ��,4 � Q a Minnesota Board of Electricity =p
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
� ��
I Describe
✓ICES /
0 to 400
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us ?;�js
e back of the white copy if necessary - the work covered by this reques`t:
' o� o� �' S�asor� ✓c_�t
GENERAL FEES Outdoor Lighting Standard $1
�ER SUPPLIES Traffic Si nal Standard $5
�ere $25 Supplemental Fee $20
�n re $50 Transformers u to 10 KVA $10
moere Ca� $75 Transformers over 10 KVA CcD $ 20
2M, COMMUNICATION, REMOTE CONTROL, SIGI
;UITS, CIRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Each Additional Unit @
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriqation Boom a(� $4(
Includes the Service andlor Power Supply up to 500 Amperes, AII
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Tri s $20
Investi ative Fee
Reins ection Fee $20
TOTALFEE Q
(minimum total fee is $20) � g,
P^ �Q� THISAREAFORINSPECTORUSEONLY
� �—
I hereby certi(y that I inspected ihe electrical installation descnbed herein on the dates stated:
Rouc'+w . onTE
-o� � Gt5
Firu� iNS�cnoN oa�
/�` � — Sr-.�
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
---------------------------------------�---� ---- _--------------------
� ���� �� ��� �� �I� �� ��� �� ��� �� ��� �� ��� �� ��� �� �� J�/�
18404608 �Q�S'" �/v���
Date: Rough-in Inspection Required? �Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
� �� You must call the inspector when ready! Date Ready:
I certrfy that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sfte SVeet Address City
S/ 7f3 .Sf ,h �c/ �✓i ��e
Township Section Range Fire No. County
�wneuvu:uyam rvnrne
�ON � /La /h I'/qG!✓��
Electrical Utility
�Xia %/ .t �r�r Ni
Please Provide Two (2) Phone Numbers Including Area Code
(�3) �38 6.s�61( )
Gontractor / Gompa ame �/ contractor �icense rvumber MeStef EICCtfiCian o� Powe� LirllitBtl TBCh�icf9�
f �/ � � � �� LicenseNumbe
Afeo.+ l.-!"<% O�c �(C�i.c ��o YZ�� �%� 7/ Z
Mailing Address (Contractor, Company or Owner Perfortning Installation)
30 ? /'�1 l �c�// l.�z !'l�G✓. S�' l�a�a� / �l� ,5' -�?,(
Authorized Sig ure (Contractpce wner Perf ing Installation) Please Provide Two (2) Phone Numbers InGuding Area Code
.�.�-- (�3)� .3s -�.s�z(�) �7 Yp� �
eurnnue nu eere nc vn i nw rnev � wnecn nc ri crrair rv cnov cwmnm e_�s n� �nu