P - 75320Minnesota Departmen �i lLabor and Industry RESIDENTIALfEL,�TRIC�AL�PER� M� B�Y CONTRA.CTOR
443 Lafayette Road PERMIT # (ei � �) � �� � �
St Paul, MN 5515 342
Phone: (651)284- RECEIV�C�fI qP��! t� � �nna
TTYRdtRS: (651) 7�198
www.electricrty.s .mn.us
Contract Re uest for Electrical Ins ection — One Famil Dwellin /Associated Structure
Date Rough-In Inspection Required? ❑ Yes Single Inspecti�n OiherThan Rough-In: � Ready Now
��5 l U� Contractor Must Schedule Ap Rou h-In Ins ctions Contractor tdiust Schedule All Final Ins 'ons �4Nill Sct�edule
Address of inspec�ion - Street CitylTovmship County-
D�0 ND S% ���.L. °— %I LE ' a�la ���
Owmer Name P1 Projed Des�iption
���� ,�-�,� � g�a � ��,� ��I�E C�.�E.
O�nmer Telephone Number(s) - Include Area Code ) i� fQ �ace TwU SP Sw��cHES Gv+7� S�i9ll� S�'C/�
% Sfo %Z �� CF� �ti7cEt e
Co�ractor Name Contrackor M�ifing Address
�/2-Id� SrO� G��c�� ZCP !9 � F 5�✓ ,�1/'ec,� �r� ��..
Contractor Telephone Number C.ontractor E-mail Addr�ss Electrical Util'ity
Z SZC S�LS �15��C'O�C�s��he� �'E�
Contrac�r Authorized Signature Contractor License tdumber • .Jflb/Project Contact Person
C � � z� � d��
Fee Calculation
New Home or Associated Structure Exisifng Home/Structure Remodel or Addition
. New Dwelfing ServkelPovver Suppy 0- 4Q0 ampere �$35 New Service/Power Supply 0- 400 ampere @$35
New Dwelfing Service/Power Supply 401 - 800 ampere @$60 New ServicelPower Supply 401- 800 ampere @$60 ,
_ . __ , i�ew Dwelltng`Fee�rs/CircuTts � �— —� - --- - - New FeerlerslCircu�s - Up to 15 FeederslCircuits _
U to 30 FeederslCirwits -$100 Feeders/Circx�its $fi Each or 16 to 30 $100
New Home - More than 30 �eeders/Circuits (in addiiion to New FeedersJCircuits - AAo2 Than 30 Feeders/Circuits
above FeedersJCircuits U To 200 A $6 Each Feeders/Circuits U to 20D A $6 Each
Ofher (Speafy) Reconnecied Feeders/Circuits
FesdersJCirc�its $2 Each
Detached Garage ar Other Associated Structure Detached Garage or Other Associated Structure
Idew ServiceJPower Supply 0- 400 ampere @$35 M1tew Service/Power Supply 0- 400 ampere �$35
New Feeder�Circuits ( ) � $s Each New Feeders/Circuits ( ) � $6 Each
Other (Specciffy) Reconnested Feeder�/Circuits ( ) @ $2 Each
Other (Specify) Other (Specify)
Tofi.�l (the fee calculated above or $35 muttiplied Total (the fee caiculated above or $35 multiplied �r sD
by the number of required inspectlon trips, by the number of required inspedion trips, J�
whichever is greater) whichever is greater)
Requests for Electrtcal Inspectlon (REI) with a%e of $250 or less e�fre 12 months from the ROng date. The corrtractor must ve the work completed within
the 72 month period or submit another REI that includes the (nspection fee forthe unoompleted work. InspecHon fees do ot qrry ovei-from one REI to
another.
q service charge of $30 wlll ba added for atl dishonored che�ks.
,� �/�- ,� - , - o �
I hereby certlty that 1 inspected the el�trical installation herein on the dates stat�: For Depa t Use Only
Rough - In Inspection(s) Date
Fjaaf'Inspection Date '
, -' ✓7b �cr
This mateMal c made avaflable in different fomis, such as large p�int, Breitle or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651} 297-4196. .
REI 02 (6/07)