P - 78496REQUEST FOR ELECTRICAL INSPECTION
1� J G�- 3 51 � Minnesota Board of Electricity -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 00-627-3529 www.electricity.state.mn.us
❑ NEW ❑ REMODEL ❑ ADDITION ❑ REPAIR Describe -using the b �l te copy if necessary - the work covered by this request:
Furnace & A/C
GENERAL FEES Outdoor Liahtina Standard l� $1 C'� � ,.�
" 0 to 200 Ampere @ $5
Above 200 Ampere �$10
ALARM, COMMUNICATION, REMOTE CONTROL
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aouaratus � 8.50
to 12 Units @$50 Per Unit
ach Additional Unit � $25
OTHER AD
nhfina Rehofit� 5.25 cerf
IIII IIIII IIIII IIIlI illll I�III IIIII IIIII �� I�
15263510
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit �$80
TOTALFEE I
(minimum total fee is $20) 2�. 51
TMS AREA FIX2INSPECTOR lbE ONLY
I hereby cer6ry that I inspec0ed the elec6ical installa6on described herein on the dales slffied:
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' COMPLETED WITHIN 12 MONTHS
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I Request Dffie: Roughin InspecGon Required? ❑ Yes � No Inspedion Other Than Rough-In: Ready Now O WNI Call
9/ 16 / 03 You must call the inspecla wh� reedy! oa�e rteaoy:
I certiTy that I am ihe [�UCENSED CONTRACTOR ❑ COMPANY � OWNER and hereby request inspection of the eiectrical work at:
�� s�ce naa.es5 �s�ree�. soX. a rw�,�e rio.� cny zP coae
7316 Symphonv Street NE Fridlev 55455432
iccupem name � /�
Da.ryl Lediri ��
Robbinsdale Electric
lirw Address (Contrac[or. Comoanv a Owner F
INSTRUC710N8 ON
P,rioka
Poease Provide Two (2) Phone Pkimber(s) I�duding Area Code
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Contractor Litxnse Number Master Electrieian or Wower Limited Tedmidan
License Number
CA01549
i)
ale NIlV 55422
,ea Phane �s)
763-588-7004
ELECTRICITV COPV E&OOOOtM14 8.1. 2002