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P - 765981�� 6 H� 7 9 5 L�. , REQUEST FOR ELECTRICAL INSPECTION �� ❑ Minnesota Board of Electricity a �„ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �. 6L�1� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriclty.state.mn.us �,� Describe,-using th% back of the white copy if necessary - the work covered by this request: �� n/ /� `, �J� C��-r [J�Y� � S! - % —'7 � � 7 SERVICES / POWER SUPPL�ES ALARM, COMMUN�CATION, REMOTE CONTROL, SIG CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Each System Device or Apparatus @$.50 ADDITIONS TO THE GENERAL FEES Each Additional Unit Center Pivot Irrigation Boom Manufactured Home Park Lc Standard Su plemental Fee $20 Transformers u to 10 KVA $10 Transformers over 10 KVA $ 20 Transformer / Power Su I for Si ns / Outline Li htin $5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT Includes the Service andlor Power Supply up to 500 Amperes, All Circuits and Two Inspection Trips Each Dwelling Unit @$80 Additional Ins ection Tri s $20 Investigative Fee Reins ection Fee $20 TOTAL FEE ,,, (minimum total fee is $20) , s L THIS AREA FOR INSPECTOR USE ONLY I herebv ceArfv thal I inspeded ihe elecUipl installation described herein on the dates sfated: �^Z3"°� I THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS I !� II ( �� I i� I� ��) �I I�� 18687954 uace: Rough-in Inspection Required? ❑Yes .�No Inspection Other Than Rough-In: ❑ Ready Now �Will Call � S^ �) You must call the inspector when ready! Date Ready: I certify that I am the�'LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ai Job Ske Street Address City % � ein �/-r��P Township Section Range Fire No. County / � 1 / 't��J� Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code �CiM�?S C%Pl/i s � )'��7 �1 � ) Installadon) � Master Electrician or Power Limited Technician I License Number \ / \ /