P - 75352Minnesota Department �f Labor and Industry
443 Lafayette F�oad North
St Paul, MN,;��155-4342
Phone: (6 ,1�� 284-5064
TTY/M , ,f`' (651) 297-4196
www.e '� 'city.state.mn.us
Contractor Re uest for Eiectrical ln
Date Rough-In Inspedion Required?
Contractor Must Sd�edule All Rou h-
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er Telephone Num Indude Area Code(s)
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RESIDENTIAL ELECTRICAL PERMIT BY CONTRACTOR
PERMIT # �Oi� � Cili��
RECE
tion - One Famit Dwellin /Associated Structure
Y� Singie Inspecfrion Other Than Rough-In: � Ready Now
:ctions Contractor Must Scheduls All Fnal Ins cfions ►(/� Will Sc�edule
C' ownship County�
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Projed Descn on �
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SGii� tsa � ��'�-� � '�`.'�'.��°
!'y�ntractor Name � Contractor Maiiing Ac
e �' �� �CS�, G,c /6 i � �� �
Contractor Telephon Number Contractor E-mail A�
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Contractor Lic�nse Number • ject Coritact rson
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Fee Calculation �G 3-� �-�-�— a 3 � 8'
New Home or Associated Strvcture
Plew Dwelfing Servi�/Power Suppy 0— 40D ampere �$35
New Dwelfing Senrice/Power Supply 401 — 800 ampere @$60
— More than 30
- $10Q
200 A Ca� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New FeederslCircuits ( ) @ $6 Each
Existing Home/Strucivr� Remodel or Addition
New 5enrice/Power Supply D— 40D ampere �$35
Newr Service/Power Supply 401 — 8D0 ampere @$60
New Feeders/Circuits — Up to 15 �eederslCircuits^ —
New Feeders/Circuits —
Each or 16 io 30
to 20U A la� 56 Each
�-��r
( ) Feeders/C'u�its @ $2 Each �
Detached Garage or Qither Associated Structure
Newr Service/Power Supply 0— 400 ampere �$35
New Feeders/Circuits
Reconnested Feeders/Circuits
Other (Specify)
( ) @ $6 Each
( ) � $2 Each
Total (the fee calculated above or $35 muttipfied TOial (tlie fee caiculated above or $35 multiplied
by the number of required 'mspedion trips, by the number of required inspection trips, �� O� m
whichever is greater) whichever is greater)
Requests for Electrieai Inspectfon (REI) wfth a%e of $250 or less ezpire 12 months from the ftling date. The contractor must have the work completed wlthi��
the 12 month period or submR another REI that fneludes the inspectlon fee for the uncompleted work. inspectlon fees do not carty ovei- from one EI to
another. y�� ""�00
A service charge of $30 wili be added for ali dishonored checks. ,5 l"`;,�r� � y� �
� �sR, �`
I hereby certify thet I inspected the electrical insMllatlon herein �n the dates stated: For De'artrnent Use Only � �p,
Rough - In Inspection(s) Date
Thfs material can b�
TDD �651) 297-4196.
REI 02 {6/07)
Date
�•'��
as large print, Braflle or on a tape. To request, call 1
) Voice or