P - 77038REQUEST FOR ELECTRICA NSP CTION-�� �
' �.� ������ � 8121 UnrvtersBy Aven�ue 3u terS 1128, Saint Pa� MDin�so� 5 04 a �' �
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� , (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
Describe -using the back of the white copy'rf necessary - the work covered by this request:
Wi�.P hlew �1�DmP
o co aoo a
Ot to 800
A ove 800
CIRCUITS, GRCUITS OF LESS THAN 50 VOLTS
Each System Device or Apparatus a$.50
ADDITIONS TO THE GENERAL FEES
MULTIFAMILY DWELLINGS PER UNIT
3 to 12 Unfls C�D $50 Per Unft
Traffic Signal Standard $5
Supplemental Fee $20
Transformers u to 10 KVA $10
Transformers over 10 KVA $ 20
Transformer I Power Su I for Si ns / Outline Li htin $5
ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Ins ion Tri s $20
Investi ative Fee
Reins ection Fee $20
C' -� TOTAL FEE ��
JC ��(minimum total fee is $20) �,
} � ]� nns u�a Foa irua�aoa use a-xr
`�( Y
I hereby cedrfy that I inspeded the electrical instal�6on described herein on ihe dates stated:
Home Park Lots $25 , f � ✓
✓ehicle Park Sites $5 F'� �"�CT10N °^TE
di ins ion $20 �" —�
'�1011 $30perHour EXPIREUTABANOONEO , OATE
�tion $.31 per Mile
.LATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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�__.._:... �� £ ���
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L 8 3 5 7 0 61,
Date: � � �
/� �� Rough-in Inspection Required? Yes ❑ No Inspectian Other Than Rough-In: ❑ Ready Now�Vill Call
You must call the inspector when ready! Date Ready:
I certiy that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER 'and hereby request inspection of the electrical work at
�o�SS��tAYv,OodS�de C� c��ri��e
Township Section Range Fire No. County
R-nb�Gl
Owner/Occupant Name Please Provide Two (2) Phone Numbers Induding Area Cade
Mco-dow v��w �ttwn�s n�3)75� 73z� ( )
Electrical Ufil' Electrical Udlity Address
�r Ce� �nz� l St $ �h e;-t n �.�,'� � �2 � �� J ���
Contractor / Company Name Contractor License Number aster Eledrician or Power Limited Technician
S']�� � j ` �� I� License Number
�, �, c t
Mailing Addre Conhador, Company or Owner Perfortning Installation)
I 4�1i � �1 � ��I� R�vcr mN 5533a
A orized Signa (Contredor or Owner Perfortning Installation) Please Provide Two (2) Phone Numbers Including Area Code
hk�75 — o� ( )
�\ UCTIONS ON BACK OF YELLOW COPV BOARn []F Fl FCTRIf:I7Y f:naV ccmrv�� e_. c o. �m.