P - 76294• I�EQU�EST FOR ELECTRICAL INSPECTION
1� 7��� C�� � Minnesota Board of Electricity
1 J 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� "' ~ ' . (�51) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.rrin.zrs
Dascribe -using the back of the white copy'rf necessary - the work covered by this request:
EXi1EL E�IEF:C��' S�t�'Ef;°S �t�JITCH
IICATION, REMOTE CONTROL, SIG
ITS OF LESS THAN 50 VOLTS
Device or Apparatus @ $.50
DDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Addfional Unit @ $25
Fee
io to
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Un(t @$80
Additional Inspection Trips @ $20
Investiqative Fee
TOTAL FEE I
total fee is $20) �� 5�
I hereby certi(y that I inspected the electricel inshallatlon describe�i frerem on the dates ststed:
9'H15 INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�pl IIIIIIIm REC'D J UN 14 2001
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�I�IIIII
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�' Rough-in Inspection Required7 ❑ Yes �] No Inspecdon Other Than Rough-In: [�Ready Now ❑ Will Call
�s� ��. % C1 � You must call the inspector when ready! Date Ready:
I c�fify that I am the [�] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JOb Site Street Address
b15� hIE �Tt�fi LN ��Ff;IF1LEY l�ii+1 55�!J�
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EfOCVipI Utility Elechipl Utility Address
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COnhactOr / Company Name Contractor License Number Master Electriaan or P
HUh! I EL,ECTF:IC CI�FiF'OFiFiTTOh! C� r����, ucenseNumber
Meiling Address (Contractor, Company or Owner Performing Installatlon)
�_�,4+� �EFi�i7:TOFiIAL RL]�td�9 St�Ihll' F'r1UL9 �li�l `�5j.14
rla�d Signalure (Contractor or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers I
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�NSTRUCTION9 ON BACK OF YELLOW COPV RflARfl !1F FI FI'.TRI(`IN I`l1GV
Area