P - 76047REQUEST FOR ELECTRICAL INSPECTION � �
1����- 0 91 6� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mtt.us
Qescr4be -using the back of t� white copy if ne��� Ihe ytork �ye�edby �i��epu�s ;� �� ��. ��
I L tfN Felav Utfi
COPAPtiUNICATION, REMOTE CONTROL, SIG
5, CIRCURS OF LESS THAN 50 VOLTS
h System Davisz or Apparatus @$.50
ADDITIONS TO THE GENERAL FEES
Unit
Fee @ $20
upto10KVA@$10
over 10 KVA C�D $ 20
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
AddiGonal Ins 'on Tri s @ $20
Investlgative Fee
Reins ction Fee @ $20
TOTAL FEE �O e 54
(minimum total fee is $20)
THISAFlE4 FOR INSPECTOR IlSE ONLY
I herebvi certiiv thffi I insoected the electrical installation described heraln on the dat� s�ted:
S iNSTALLATIQN MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS ________�
��������������������i����������1�������� 'lt�� �
1787091b
C�c � ��
��� Rough-in Inspection Required? ❑ Yes� �] No Inspection Other Than Rough-In: 0(Ready Now �Will Call
���' �ja$ You must call the inspector when readyf I Date Ready:
I c�ify t#tat I am the L� LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
JobSiteStreetAddress c�ryFFtIDLEY I%hl .c1�iQ�.'yL—
5755 i�lE L�ASHThIGTOh! �T � , ,�
I�E�tY�ihIGAR ,.i0HP1 D
�IeCtricelu�n� Electrical Utility Address
XCEL EhlEFiGY
Carrtractflr / Company Name
HU�1i ELECTRIC COfiF'OfiATIOh�!
A4aiNn$ Addr�s (Contractor, Company or Ovmer Performir
" ���0 TEF�F:T1"O�:T�iL FiOAi?q Sta
Auifiprked Signature (Contractor or Owner Performinq In
� �
f�i�QKA
me Numbera
� �
:ontractor License Number Master EI�trlcian or P
�A OQ�s;j ucense Number
9 f�hl 5511�
Please Provide Two (2) Phone Numbers
�65� 64b—�911 � �