P - 75939REQUEST FOR ELECTRICAL INSPECTION �'
1����- 4 0 9 0 Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minn�ota 55104
(651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.rreqr.us
Describe -using the back of the white copy'rf nec;essary - the work coveredpli �S f�l '/ ., 7 l/1 ��(%
0 to
)MMUNICATION, REMOTE CONTROL,
CIRCUITS OF LESS THAN 50 VOLTS
iysfiem Device or Aaaaratus (�a. $.50
5 I on @$.31 r Mfle
THIS INSTALLATION MAY BE ORDERED DISC(
(ull IIIII Illu II�I II�I IIIII IIUI �III �� I�
1928409�'
Transformers W 10
Transformers over 10 t
Trans(omrer / Posver S.
ONE & TWO FAMILY DWE
Includ�s the Senrice and/or
Circuits and Two Ira�don
Fee
wer Suppty up to 500 Amperes, AA
ps Each DwelGng Unit @ $80
@ $20
TAL FEE
fee is $201 (
� nereey cert'dy mat 1Lisp�d 8re etecUicel insmuanon d�mb� nerem on Bre aates �ed:
nana� w or,�
�ai ws�cnai ��
Y 7- IZ-�'
IF NOT
FOR OFFICE USE OA�LY
� ��� - �o�-��
� Rough-in Inspecdon RequUed? ❑ Y� No tnspedion Other Than Raugh-Im��Ready Nap ❑NM Ca0
You must cell the Inspedor when readyi Date Raady.
I ce that I am CENSED CONTRACTOR -� COMPANY ❑ QWNER and hereby request inspecdian of the electricaFarork at
.�b�s�Z� �,� �` Q°��.�I/ , �1i� �� f�l �.�'
��
VALLEY HEATING &
Ilon)
ra�, MN 55429
u� N�
auaaon) Please Provide Txro (2) Phorre Numbers Includh�g Area Code I
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. BOARD QF ELECTRICITY COPY � . EB-00001A-16 8.1. 2004