P - 78374'7 REQUEST FOR ELECTRICAL INSPECTION
1��} �' 1� 8 6 6� Minnesota Board of Electricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
C�4�''�q'� (651) 642-0800 TTY/MRS 1-800-627-3529 www.electriciry.state.mn.us
❑ NEW EMODEL ❑ ADDITION ❑ REPAIR Describe -using the back of the white copy if necessary - the woAc covered by this request:
�b C ��.: s � ;-� cc� s�� `�-z-► - `7 $ �s
GENERAL FEES Outdoor Li htin Standard $1
SERVICES I POWER SUPPLIES Tra�ic Si nal Standard S5
� Above 200 Ampere �?$10 '
ALARM, COMMUNICATION, REMOTE CONTROI
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
$50 Per Unit
Unit @ $25
Pivot
ONE & TWO FAMILY DWELLIN6S, EACH UNIT
Includes ihe Service andlor PaNer Supply up to 500 Amperes, All
Grcuits and Two Inspection Tdps Each Dwelling Unit @$80
TOTAL F� I
(minimum total fee is $ )
THISAREAFdi dLY
I hereby ceNy that 1 inspected the electrical insfalla0on described herein on the da�s sfaEed:
S allns on �30 Hour - I
Soecial InsoecUon � S 31 cer Mile
� THIS INSTALLATION MAY BE ORDERED DiSCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
(II�I �IIII II III IIIi� IIIII IlIII IIIII II�I� �� ���I �J� j,,
14978662 �'T��(�
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Raquest Date: Rough-in Inspedion Required? ❑ Yes Inspection Other Than Rough-In: ❑Ready Now VYYII Call
a, �3 Vou must call �e inspeclor when ready! Date Ready:
I cefi(y that I am the �CICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request �spection of Ihe electrical wak at:
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rvide Two (2) Phone Number(s;
1 1- loiS�( � )
neaster �ecmaan or
License Number
iws�muc-a�+s on e�cu oF reuow BOARD ELECTRICITV COPV e�0000u-u a�. zaae