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P - 761752-00��503 � Describe -using the �ck of the white �py if ne� � �` '- GENERALFEES 401 to 8(10 AbUYe EOO REQUEST FOR ELECTRICAL INSPECTION Minnesota Board of Electricity 1821 University Avenue Suite S-128, Sairrt Paul, Minnesota 55104 ��" (651)642-OSOOTTY/MRS 1-800-627-3529 www.electriciry.state.mn.us )MMUNICATION, REMOTE CONTROL, SIGNALING CIRCUITS OF LESS THAN 50 VOLTS MULTIFAMILY DWELLINGS (PER UN� 3 to 12 Units @$50 Per Unit Each Addi6'onal Unft @ $25 OTHER ADDITIO Liahtina Retrofit an. $25 aer Focture Fee @ $20 up to 10 KVF over10 KVA ONE & TWO FAMILY DWELLINGS, EACH UNR Includes the Service andlor Power Suppfy up to 500 Amperes, All Circuits a� Tvro Insp�on Trips Each Dvue�ing Unit @$80 Addi�onal Ins 'on Tri $20 iti Investigative Fee Rei� 'on Fee $20 TOTALFEE ,�/ (minimum total fee is $20) 7 �� TM9 ARFA FOR @LSPEC(OR LLSE 0lRY I hereby cerdty that I inspected the elechicel ir�stelladon described herein on the dates steted: Raai w un� � �G_� �� !-1 �-�6° �t i eTION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS t;rl r��'F,;;_ � �tiC � udl'; �IIIItII11111II11I�IIII��I11�lU��l� r 20085031 � ��I� �� Rough-in Ins�Ction Requtred9 ❑Yes �No Inspedion OtherThan Rough-In: ❑ Ready Now�wO Call 9/� �/ Q� You must rall the inspec[or when readyl Date Ready: , I cerGfy that I am the LICENSED CONTRACTOR � CAMPANY ❑ OWNER and hereby request inspection of the electrical wark at Job Si[e Street Address �nN `7� �' �P �aVl � ul��-vl � �� TaMmship SecUon Range Fire No. CouMy �k� pyme�/°�' paz�t ryeme Please Provide Two (2) Phone Numbers Irtcluding Area Code /�0 tmt �5. ��.iv��or�� $'-��- � ) Elactrical Utllity Electrlcel Utllity Address � �� ling Address (Contrador, pan or Oamer Pertermirtg Insta�aUOn) 2672 Mapl eau o Dr. , Mapl�bod�MN 5 horized Sfa�mture ( or Ormer PerfortNn Master ElecMdan m License Number (65�-484-8044 � )