P - 79111REQUEST FOR ELECTRICAL INSPECTION
1� 7 C� 0� 4 6 5�6 Minnesota Board of Electricity
t821 University Avenue Suite S-128, SaiM Paul, Minnesota 55104
�� �ao'� (651}642-OBOOTTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW �REMODEL ❑ ADDITION 0 REPAIR Describe •using the back of the white copy 'rf necessary - the work covered by this request:
�� ��c��SU �,,. Co� 1- � —1 "� - �1� ��'
Traffic Sianal Standard
0
Above 2071 Am re $10 � Includes the Service andla Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circui� and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Mdifinnal Insn�,c:tinn Trins Fil S?0
Fee
I V��CLLII�W rCf�Vl�ll IVI/'1LrCL h �JV,
3 to t2 units @ E50 Per Unit (minimum total fee is $20) CX �
EaCh Add160na1 Urlit �$25 Tws uu� Foa wsvECroa usE aar
I herebY certiy Ihal I inspecEed the electrical insfalWUon described herein on the dafes sf�ed:
OTHER ADDITIONAL FEES n I J� � f r, %`� `'� h��—
Uahtina Retrafit �$.25 cer Fixlure % `'f' l../ =.L./��1
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17�04656 �60 �
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Request Date: Rou�� ��sPeetion RequNed? Yes No Inspedion Other Than Raugh-In: �Ready Now Call
'—�j'" ��"i You must can tAe inspeUar when readyl paie RgpMy; .
1 oertidy that I am ttie �CICENSED CONTRACTOR ❑CONPAiJY d OWNER and hereby �t inspection of the electrical work at: