P - 75790pc ''] REQUEST FOR ELECTRICAL INSPECTION '
�� O v,1 � 616 � Minnesota Board of Electricity
��„ : 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104
_, (651) 642-0800 TTY/MRS 1-800-627-3529 www.edectricity.state.mn.us
Describe -using the b of the white copy'rf n the work covered by this r�u ,: q
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GENERAL FEES Outdoor Lighting Standard @$1
ERVICES / POWER SUPPLIES Traffic Si nal Standard @$5
0 to 400 Ampere $25 Sup lemeMal Fee @$20
401 to 800 Am re$50 Transfortners u to 10 KVA $10
Above 800 Am�re (� $75 Transformers over 10 KVA na $ 20
� CIRCURS, CIRCUITS OF LESS THAN 50 VOLTS
Each Svstem Device or Aooaratus fiD $.50
Unft @
� Retrofit @ $.25 per Fodure
Pivot Irriaation Boom CaD $40
Includes the Service andlor Power Supply up to 500 Am{�res, All
Circuits and Two Inspection Trips Each Dwelling Unft @$80
Addfional Ins 'on Tri $20
Investi ative Fee
Reins 'on Fee $20
TOTALFEE
(minimum total fee is $20) �
TFUS AREA FOR P15PECT@t USE qVI.V
I hereby certify fhat I inspeded tlre ele�ical tr�falladon desafbed herem on fhe dates slated:
�THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOLCOMPLETED WITHIN 72 MONTHS
. "OR �JrFIi,E ti�:r OtlL'✓
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"°�/� �^ Rough-in Irrspectlon Required7 ❑Yes �o I Inspectlon OtherG i�� In�� y Now ❑Wm Ca0
� ((� You must cell the inspector when readyl Oate Ready:
I cerMy tliat I am the�1JCENSED COM'RACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site Address �gy
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Electrical Utl�ftY Electrical Utiliry Addresa
CoMracror / Compeny Name Contrador Ucense Number Master Electrician or Power Limited Technician
Ries Electric Company CA01539 u�"�"'°"�'
Mailirtg Address (Contractor C erforming Ir�tallaUon)
77 on S , o . Paul, MN 55075
orized S �e ( r or Oxmer Perto nsteVad Please Provide Txro (2) Phone Numbers Induding Area Code
�651� 451-2238 � )
�N BACK OF YELLOW COPY BOARD OF ELECTRICIT/ COPV FA-OtM01 A-15 A � 7nna