P - 75358��3��3�
Minnesota De artment of Labor and Industry
443 Lafayett oad North
St. Paul, MN 55155-4342
Phone: (65 2845064
TTY/MRS: 51) 297-4198
www.elec ' tv.state.mn.us
Contractor/Re istered Em lo er Re uest for Electrical Ins ect
Dat@ Rough-In lnspection Required? � y� Single Inspection Other Than Rough-In:
10/29/08 Contractor/Em lo er Must Schedule AII Rou �h-In Ins ectlons Contractor/Em lo er Must Schedule AII Final Ins
Address of Inspection – Street City/Township County
4527 - 2 1/2 STREET NE FRIDLEY ANOKA
Owner Name Project Description
JOHN THOMPSON WIRE GAS FIREPLACE
Owner Telephone Number(s) – Include Area Code(s)
(763) 502-7706
Contractor/Registered Employer Name Contractor/Registered Employer Mailing Address
COLLINS 278 STATE STREET ST PAUL MN 55107
Contractor/Employer Telephone Number
- =�(�1 j�`t4=2�`3�-- -_----- --- -
Co�tod�mqloye,r�uthorized Signature
ConVactoNEmployer E-mail Address Electr
Contractor License Number Job/P
CA00406
Fee Calculation
Service/Power Supply 0– 400 ampere @$35
Service/Power Supply 401 – 800 ampere @$60
Service/Power SupplY Above 800 ampere @$100
New/Extended Feeders/Circuits Up To 200 A( �)@$6 Each
Feeders/Circuits Above 200 A
Reconnected Feeders/Circuits
(
(
Manufach�red Home Park Lot Supply (
Recreational Vehicle Site Supply Equip
( ) Circuits Originating in the Ec
Street, Parking Lot, Lighting Standard (
Transformers Up to 10 kva '` (
)@$15Each
) @ $2 Each
) @ $35 Each
@ $6 Each
) @ $5 Each
)@$15Each
Technology System Devfces ( )@ 75¢ Each
Separate Bonding Inspections for Swimming Pools and
E ui otential Planes $35 Each
Center Pivot Irrigation Booms ( )@$35 Each
- - — ?aus EI��4 DriuP Unita_ Each
$6 Luminaire Retrofit Modifications ( ,)@ 25¢ Each.
' Ready Now
' Will Schedule
Concrete-Enqsed Electrode Inspection ( ) @ $35 Each
Special Inspection Fee ( ) Hours @$80 Per Hour
Plus ( 1 Miles (a� The IRS Mileaqe Rate of (
�iV@i FivQ �i0i�i — Add C-�0 tomGirletl set�iGJpo:ve.• Sl7pply 2r.d feedeN. Ci2��R fe9 to
result in double the reguiar fee (does nol appiy to electric sign and outMe ligh8�)
( ) New Multi-Family Dwellings @ $70 Each
With Up To 20 Feeders/Ci •uits �
Transformers Over 10 kva ( )@$30 Each ( ) Additional Circuits Above The 20 Allowed Per Unit
6 Each
Electric Signs and Outline Lighting Total (the fee calculated above or $35 multiplied
Transformers/Power Su lies $5 Each by the number of required inspection trips, �� 5O
whichever is greater)
Requests for Electrical InspecUon (REI) with a fee of $250 or less expire 12 months from the flling date. The contractor/employer must have the work
completed within the 12 month peHod or submit another REI that includes the inspectlon fee for the uncompleted work. lns����� carry over
from one REI to another.
A servlee charae of S30 wlll be added far all dishonored eheeks_
I hereby certify that I inspected the
Rough – In Inspection(s)
on
Date
1-yrlal 11 IA�.JGI:II V I I �J,
� %% �
This material can be made avatlable in dlfferent forms, such as
TDD (651) 297�198.
REI 03 (6/07) ,
For Department Us� Oli�y� W
�o�' � I l➢ 1 �
I�ECD OCT 312008
or on a tape. To request, call 1-800-342-5354 (I
or