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P - 76895a Minnesota Department of Labor and Industry 443 Lafayette Ro North St. Paul, MN 5 5-4342 Phone: (651 4-5064 TTY/MRS: 1) 297-4198 www.elect ty.state.mn.us Contr ctor Reguest for Electrical Ins D�t�:�.� � � Rough-In Inspection Requlred? 1..,, Contractor Must Schedule All Rough-In Address o nspection - Street � � �� ��� ; D-��-� �� � ,��c� �-�1�3� REC'D � C T- 4 2007 tion — One Family Dwelling/Associated Structure Yes � Single Inspection Other Than Rough-In: � Ready Now �ctions Contractor Must Schedule All Final Ins ections ❑ Will Schedule � Ciry/Township Co�nty , _. _ __ �er ame !� P oject Descnp, ; � 1 � C1�� 1����r� � i elephone Nur�r s) - Inctude Area Code(s) Z- ��� �'1 � ,/� � /�. � ' � `-- ` 1..- �i � �� 3L �i ( � � �"3 . l l tractor Name _, , Contractor Mailing Address �r �•--�.�--c,L� __ ��_ \f _: L: �`i�' �- C Contractor Telephone Number -. � Z Z-`�-� �i-`�i � Con t r Aut � riz Signature /` - ���:�.:��.�-- ->-. Contractor E-mall Address c i>�c:c-�-.ti-,�-.,r �::3-�SA- � .�-i ' �j-- w�c� L �- ��1�� Electrical Utility --___ _ _ --- -- Contractor License Number Job/Project Contact Person ' � c.C' --- � �t=���- � =_= ' -- - _ _ Fee Calculation New Home or Associated Structure New Dwetling ServicefPower Supply 0- 400 ampere @ T35 New Dwelling Service/Power Supply 401 - 800 ampere @$60 New Dwelling FeedersiCircuits Up to 30 Feeders/Circuits - $100 New Home - More than 30 Feeders/Circuits (in addition to above) ( ) Feeders/Circuits Up To 200 A@$6 Each Other (Specify) Existing Home/Structure Remodel or Addition New ServicelPower Supply JQ(i 0- 400 ampere @$35 I New Service/Power Supply F 401 - 800 ampere @ �60 s- Up to 15 Fee� ( If� ) Feeders/Circuits @$6 Each or 16 to 30 @$100 NewlExtended FeederslCircuits - More Than 30 Feeders/Circuits Feeders/Circuits Up to 200 A@$6 Ea�h —�----�--- Reconnected Feeders/Circuits � 1 Feeders/Circuits @ $2 Each _----- -----�---- - ___ __-- -_ _ _ - Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure New Service/Power Supply New Feeders/Circuits Other (Specify) 0 - 400 ampere @ $35 ( ) @ $6 Each New Service/Power Supply 0- 400 ampere @$35 New/Extended Feeders/Circuits ( ) @ $6 Each Reconnected Feeders/Circuits ( ) @ $2 Each _._. — ---_ ---- -- __- ------ - Other (SpecifY) Other (Specify) , � Total the fee calculated above or $35 multiplied �' `J TOt81 (the fee calculated above or $35 multiplied � �� by the number of required inspection trips, by the number of required inspection trips, whichever is greater) whichever is greater) Requests for Electrical Inspection (REI) with a fee of $250 or less expire 12 months from the filing date. The contractor must have the work completed within the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to another. A service charge of $30 will be added for all dishonored checks. I hereby ceRify that I inspected the electncal installation herein on the dates stated Rough - In Inspection(s) Date r v� v��y Finallnspection Date I .- G � -�� �'l � �_� _ _ ______----- This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.