P - 75479Minnesota De
443 Lafayette
St. Paul, MN
Phone: (651 �
TTY/AARS: �
Date
7.3.08
�nent of Labor and Industry
ad North
55�1342
h5064
297-4198
ate.mn.us
r Re uest for Electrical
Rough-In Inspecfion Required?
r�uu�ca� vi n�arF�cc;uuii — aur.
6745 CHANNEL ROAD
OwmerName
KEITH PETRICK
Owner Telephone Number�s) — Include
RANDY'S ELECTRIC
Contraetor Telephone Number
(763) 295-6558
23423585
I Illu� IIIII II
III IIIII III
II IIIII IIIII
IIIII IIII IIII
,tion - One Famil
y� Single Inspection
FRIDLEY
Than Rough-In:
de All Final Insrn
ANOKA
zracture
Ready Now
Will Schedule
INSTALL A 20 AMP CIRCUIT TO THE SUN ROOM.
(763) 205-4757
Contrac[or Mailing Address
1455 OAK RIDGE CIRCLE MONTICELLO, MN 55362
Utility
vvnuov vi �uu�v��vu v� ��aw�c vVnua�dV1 LR.OIIaC IY4111YC1 JVD/r1�7�C2G1 l,Ofll-dG[ f"P.lSUfl
-;��'°,- CA03884 RANDY 612.490.3356
Fee Calculation �
New Home or Ass�lated Structure Exlsting Home/Structure Remodel or Additlon
New DwelGng Senricc�/Power Supply 0— 400 ampere �$35 New Service/Power Supply 0— 400 ampere (4�D $35
New Darelling Servic:e/Power Supply 401 — S00 ampere @$60 New Service/Powrer Suppy 401 — 800 ampere (� $60
New DweUing Fesders/Circuits Ne�rlExtended Feeders/Circuits — Uo to 15 FeederslCircuits
0
Feeders/Circuits
uoru�.uwu� -
(in addidon to
Detached Garage or Other Associated Structure
New ServiceJPower Supply 0— 4Q0 ampere @$35
New FeedersJCircuits ( ) � $6 Each
— More Than 30
Detached Garage or Other Associated Structure
New Servioe/Power Supply 0— 400 ampere �$35
New/Extended Fe�ers/Circuits ( ) c@ $6 Each
Reoonnected Feeders/Circuits ( ) � $2 Each
�
Other (SPQ�Y) Other (SPBCifY) �
Z r� � o
TOtai (the fee calculated above or $38 mulUplisd TOtdl (the fee calcwlated above or $35 mukiplied
by the number of required ins�ion trips, . by the number of required inspection trips, �% �a� �
whichever is greater) whichever is greater} �
Requ�ts for Electricet Inspectlon (REI) wlth a fee of $250 or less explre 12 months from the flll� date. The contractor muat have the work eompleted wlthln
the 12 marhh period or subm(t another REI that irtcludes the Ins�on fee for the um:omplet�! work. Ins�on feES do not carry over from one REI to
another.
� l JI l� � A service charge of 530 wlll be added for ail dlshonored checks.
1 hereby cerdfy that I inspected the etectrical installatfon heretn on the dates stated: For �part�rrent Use Only
Rough — In Inspection(s) Date ���� � � �„� �
Final spection Date �� AvG 1�. �00�
� � � � �.�
This mater�al can be � e avellable In difRereM focrt�, such as large prl Brallle or on a tape. To requ�t, call 1-800-342-53t4 (DIAL-DU) Volce or
TDD (661) 287�188.
REI 02 (6/0�