P - 76029REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 7� O 8 5 � Minnesota Board of Electricity •;
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the 6ack,.of the white copy 'rf ne��,p�.:1he Wrork �cg��y �i���.-�.�IPCt: S SW I T C H
l.tL ti4th i�tf�;
GENERAL FEES Outdoor LighGng Standard @$1
SERVICE J POVIIER SUPPLIES Traffic Sianal Standard �$5
3PAMfUNICATiON, REMOTE CONTROL, SIGNALING
CIRCUITS OF LESS THAN 50 VOLTS
iVStem Device or Apparatus C�a. $.50
Boom
Mile
IIIINWII��IIIUIIIu���II�IIIIIIIIIII��
y7870858
Transfortners over 10 KVA $ 20
Transfortner I Power Supply for Signs I Outline Lightlng @$5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dweliing Unit @$80
TOTAL FEE �(]e
total fee is $201
thffi I inspected the electripl Installatlon described herein on the dates sfated: �
���
IF NOT COMPLETED WITHIN 12 MONTHS
��� �(.�1�� l
�e� Rough-in Inspection Required7 ❑Ye � No Inspecdon OtherThan Rough-In: [):Ready Now �WIII Call
S'�.Q�d�i
You must call the inspedor when ready! Date Ready:
I c�rt�y tltet I am the C� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JobSiteStreetAddress �m'�ri���.� {�� �9„r"t�JL"
b556 S7IhlSOh� I�L�'D 474�
Townahip Section Range Fire No. County
AhIOKA
Oem parrt Name Please Prov(de Two (2) Phone Numbere Includirtg Area Code
� �sr,� �wor�AS �� ( ) ( )
Electricel U' Electrical Utility Address
�CEL�hfEFiGY
C9Rtrectpr / Compeny Name Contrsctor License Number Mester Electrician or Power Limited TechNcl
I-Il1hl� ELECTF�.'IC CQFiF'OFiAi"IGhi C(� �J48$;'s U�enseNumber
Ma;Hnay Add[gss_ Contractor, Company or Owner Performin Installation)
�a00 i'���aTTO�:I�iL FiOADq SA�hIT F'AUL9 hlh! 55114
AyL�Qif3ed $tgnaWre (Cantractor or Owner Pertorming Inslaliation) Please Provide Two (2) Phone Numbers Includinp Area Code
�s�� �4�-�4�� �