P - 75378� Minnesota ^Departrnent �f Labor and Industry
443 Lafa}y�fie Roaci Nor[fi
St Pa f`"��11N 55155-,4342
Pho (651) 284-5064
RS: (651) 297-4198
.electricity.state.mn. us
ontractor Re uest for Etectrical ins
Date Rough-in inspection Required?
� v� 0 Contractor Must Schedule All Rou h-In
Address of Inspection — $treet
errnr.��+--�-
Contractor Name
% iG'1 C�Lf�ll `( ;
Co tractor Telephone Plumber
7/ Z 7 c—C r�%,..
RESIDENTIAL ELECTRICAL PERMR BY CONTRACTOR
PERMIT# �JC���DI ��O
RECENED: 1�C,� OCT 1 O ZOO7
tion — One Famil Dwellin /Associaied Structure
y� Single Inspection Other Than Rough-In: � Ready Now
:ctions Contractor Must Schedule All Firtal Ins�e�tions � Will Schedule
� �d �
Projed ption •
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�S� �ril �!� ►1-e c.� l U 0��M ��r�el�i� P� n� l
a e�v �ei G �
Contractor Maiting Address
r � �% � �/G�� � .S�
Cantrador E-mail Address Eledric�l Utitity
Cflntractor
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Person
Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addiiion
Plew Dwelfing Servi�/Paaer Supply 0— 40D ampere �$35 New Senrice/P�vver Supply �.� �0 — 400 ampere �$35 �?�
New Dwelling Servi�/Prnaer Suppiy 401 — 80D ampere @$6D Newr Senrice/Power Supply 401 — 8D0 ampere @$60
Alcw Il�r.�cllinn CoerlArc/f`_irrv�i4c -. .-Ucw Fr.�rinrclf _aehttfc _ f In� 4n= i5 �wa�a�rc/f _irr-i� —� ._
U to 30 FeedersJCircuits - $10D
— More than 30 �eeders/Circuits (in addition to New
) FeedersJCircuits U� To 200 A C� S6 Each
Detached Garage or Other Associated Structure
New Senrice/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) � $6 Each
Other (Specify)
Reconnected
— More Than 30
16to30(iD$100
A (a� $B Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere �$35
New Feeders/Circuits
Reconnested Feeders/Circuits
( ) @ $6 Each
( ) � $2 Each
Total (the fee calculated above or $35 multipfied To�l (the fee calculated above or $35 multipGed
by the number of required inspedion trips, by the number of required inspec�on trips,
whichever is greater) whichever is greater) �.��
Requests for EIe�cLical Inspection (REI) wfth a iee of $250 or less explre 1 Z months from the ftling date. The eontractor m�t have the work completed within
the 12 month period or submR another REI that includes the (nspectfon tee for the uncompleted work. lnspection fees do not carry ovet from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
I herebY cQrtiN that I inspected the el�trical installation herein on the dates stat�: For Department Use Oniv
Rough — In inspec6on(s)
�al Inspection t �
Thts material can be ma e a
TDD (651) 297�4198.
REI 02 (6/07)
Date
Date
� �� °�
as large p�int, Braille or on a tape. To request,
or