P - 76181REQUEST FOR ELECTRICAL INSPECTION '
2 � � 4 � ° � � °Z � Minnesota Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
(651)642-08001TY/MRS 1-800-627-3529 www.electricify.state.mn.us
Describe -us'�ng the back ofRhe white copy if nec�ssary - the work covered by this request: �^„_ �
► � 1 � _ „ n . . / w ���`-.
401 to 800
Above 800
CIRCUITS OF I.ESS THAN 50 VOLTS
ipstem Dsvice or Apparatus @ $.50
ADDITIONS TO THE GENERAL I
Hour
I�I u III �I I� ��� ��� �� u� II UI �� (�
?04�3626
Traffic Signal Standard @ $5
Su lementel Fee $20
Transfomrers u to 10 KVA $10
Transfomrers over 10 KVA $ 20
Trarisfortner / Power Su I for SI / Outfine Li hti $5
as
ONE 81W0 FAMILY DWELLINGS, EACH UNIT
Includ� the Service and/or Power Suppiy up to 500 Amper�s, Afl
Cirarits and Two Inspection Trips Each Dwel6ng UnR @$60
Additionallns 'onT' $20
Investl ative Fee
Reins on F� $20
TOTAL FEE � � � �
(i imum�total fee is $20)
rws a�a roa usrECrors us� om.v
I hereby cmtif�lthat I N� the electricel fnsteliatlon d� herefn on Nre dat� s�ed:
q� a oa�
Fwai.wrsv�cnoN ' uate
1�. �Z—�0,�
�,� ��
►�%�_rJ�I_�unL _ _eLU�Latu�_w_9_a�In. �
FOR OFFICE USE ONLY
����� ���� .�
��' RougFNnlrrepectlon R utredT ❑Yes o I
eq nspectlon Other Than Rough-In: [�,�eady Naw dVAI Ca0
� 1 � 0 W You must call the inspec[or when readyl Date Ready: ?
I certify that I am the J�9JCENSED CONTRACTOR ❑ COMPANY ❑ OWNER artd hereby r�uest inspedion of the electrical work at
Job Site Street Addreas Ci(y
3�� �,� . rl ;.,. a fl_ aJ� �-.n.�.dlSlo,a�
0
(9,s� g73 - �89� �
� Nw� nn� ��ae
� , IL u�rree Numb�
( � 55 a-87b�