P - 75416Minnesota Dep nt of Labor and Industry
443 Lafayette oad North
St Paul, MN 5155-4342
Phone: (65 264-5064
TfY/MRS: 1) 297-4196
v�ww.el ' .state.mn.us
Con ctor Re uest for Electrical l
�� � Rough-In Inspection Required?
t�!� ���'6 Contractor Must Sc�edule Aq Rou I
Address of Inspec�ion - Street
l 7 S C�c�« 6 r�o K(��—
Owmer Name
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RESIDENTIAL ELECTRIC�►L PERMIT BY CONTRA.CTOR
PERMIT #
RECENED:
tion — One Famil Dwellin /Associated Structure
y� Single Inspection Other Than Rougfi-In: Ready Now
�ciions ContracEor Must Schedule All Final ins ctions Wip Sdiedule
Cityffownsh' Co�nty
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Projed Descxip n
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Cordrador Name Contrador Maiiing Address
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Contrackor Telepfione Numher Contrador E-mail Addr�ss Eleefic�i Ufil'ity
�la-�O`f- S7OZ �K� Pete�So�J��a���ASt,/�et X ��lf
Co ctor Auilwr¢ed ig ature Contractor License Number • Job/Projed Contact Person
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Fee Galculation
New Home or AssociaEed Structure F�cisting Home/Strvcture Remodel or Addition
New Dwelf'mg Serv►c�/Pouver Supply 0— 400 ampere �$35
New Dwel{'ing Service/Power Supply 401 — 8Q0 ampere �$60
New Dwelling Fe.ederslCirc�its
New Home — More than 30
200 A
�
m
Detached Garage or OEher Associated Structure
idew ServicelPower Supply 0— 4DD ampere �$35
New Feeders/Circuits
Otl�er
( ) G $s Each
New Service/Power Suppy
New ServicelP�wer Supply
New Feeders/Circxtits — Up to 15
D — 400 ampere � $35
401 — 800 ampere � $60
( ) FeedetsJCircuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 40D ampere @$3b
New FeederslCircuits
Reconnested F�ders/Circuits
Other(S�ciy)
( ) @ 56 Each
( ) � $2 Each
o- 50
Total (the fee calcx�lated above or $35 multipfled Total (the fee caiculated above or $35 muftiplied
by the number of required inspectlon trips, by the number of required inspedion trips, � v �0
whichever is greater) whichever is greater)
Requests for Electrical Inspectlon (REIj with a%e of $250 or less ezplre 1 Z montlis from the ftHng date. The contractor must have the work completed within
the 12 moMh period or subm(t another REI that inciudes the ins�on fee for the uneompleted worlc. Inspee8on fees do not earry over from orre REI to
enother.
A servlce charge of $30 wiil be added for aq dfshonored cheeks.
I hereby certify that I inspected fhe et�triaal installation herefi on the dates stated: For Departrnent Use Only
Rough - In Inspedion(s) Date
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Final lnspection � , � Date
�° �_ _�`= �� �`°�_s �;�Z-��-�, �
This material can be made avaflabie in different fortns, such as large prir
TDD (661} 297-4798.
REI 02 (6/07)
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or on a tape. To request, call 1-BUO-342-5354
or