P - 76267• REQIJEST FOR ELECTRICAL INSPECTION ��
1�� 7�- 519 � Minnesota Board of Electricity
�_�- 1821 University Avenue Sufte S-128, Saint Paul, Minnesota 55104
' , (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the whfte copy'rf necessary - the work covered by this request:
E?:CEL EhIER�`( aAVEfi'a 5�l2T�H
GENERAL FEES Outdoor Lighting Standard @$1
SERVICES / POWER SUPPLIES Traffic Sianal Standard (a� $5
CIRCUITS, CIRGUITS OF LESS THAN 50 VOLTS
Each System Devk;e or Apparatus @$.50
ADDITIONS TO THE GENERAL I
3to12
Transformers over 10 KVA $ 20
Transformer I Power Supply for Signs / Outline Lightin $5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dvrelling Unft @$80
TOTALFEE
total fee is $20) �� ���
5 pef FiXture � � I hereby certiy that I inspected the electrical instslladon da9cribed herain on the da0es stated: �
��m � gqp POUGH IN �,�
.s��`T I
Special Inspection @$.31 per Mile I I
S IAISTALLATIOPI MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
�pII�I Ip II�1II REC'D ,1UN 14 2007
I�II �INI III� �IIII I��BI IIU� B�� �l�f ��l� �
�� 7 9 7 51 `9 4 Q����'���'��'
V°�' Rough-in Inspection RequiredT ❑Yes � No Inspection Other Than Rough-In: �Ready Now ❑Will Call
c�i ��. �. %�;� You must call the inspector when readyl Date Ready:
I certify that I am ths �1 LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electriql work at
JobSiteStreetAddress ���FiI�LE'� i�ih! 55��L
5bb�; ��tV�i�i.li-',i� F'fiSS t�
To�eh�P Section Range Fire No. Caunty
F[ihiTAI�fE A��F�C�hI �l ( � ( �
Electrical Utility Electrical Utility Address
X! �EL E�lEF�G �
ConVac4or / Company Name Contractor License Number Master ElecMcian or P
HUFlT ELEC1"�;TC CQF:F'i]fiATT�h1 CA f?4�$.:r ucenseNumber
Ma�7(ng Addresa (Contractor, Company or Ovmer Perfortning Installation)
�,:�OC� TEhhTTOF�I� �� ��R�q S�iIf�T F��ULq �ihi 55114
Aqf�m�6�ed $ignature (Contractor o Owner Perfortning Installation) Please Provide Two (2) Phone Numbers
era� r (55� 6��-��ii ( �
mua7aur.ntwc nu wer.r nc vci � nw nov o.,�o� .,� �� ��TO���,.. �..�..