P - 75355Minnesota Dep ent of �abor and Industry Ft�E1D�NTlIelL �LECTRICAL PERMIT BY COIVTRACTOR
443 Lafayette ad North
St Paul, M 155-4342 PER1N'IT #
Phone: (6 ` 284-5064 pi�CEN�D: .
7TY/MR (651) 297-4198
www.el 'cc�tty.stete.mn.us
Contractor Re uest for Electrical Ins �:ci�c�n — �n� Fa�mi! D�ve�1F� JAssflc�afi�d �tr�tc�re
��/ Rough-In Inspectien Required? Yes 5i�gle Inspec�ion Other?'han Ftough-In: Ready Now
`�(� ( 0 e Contractor Must Schedule All Rou h-In Ins dions Contractor Must Schedule All Final Ins ctions � Will Schedule
Address of inspedion — Street CityfTownship County
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Owner Name Pro'ed Description
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OwnerTelephone Number�s)— Indude Area Code(s) Rc►4�i o�tkfi a{ e� s��•k w►if� Gft •
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C�rrtractor Name Contrador Mailing Address
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Contrector Telephone Number Contractor E-mail Address Elec�rical Utility
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Contradar Author¢ed Signature Contractor Li�nse Number • Job/Project Contact Person
C%1-D 20 � oES�f�E�-
Fee Calculation � �� _ t� ���- 313�3
New Home or Assaciated Structure Existing Home/Structurs Remodel or Addition
. New Dwefling Servir�/Pawer Supply 0— 4a0 amaere �$35 New Service/Pewer Supply 0— 4Q0 ampere @$35
New Dwelling Senrica/Power Supply 401— 800 ampere @$6.0 New SenricelPower Suppy 401— 800 ampere @ S60
-- - idew Dwalfi� �Feeders/Cifc-aits -- - New Fe�de�fEi�cwits — Up to 35 Feede�sJ�irc�i�— --
U to 30 Feeders�Cir�(ts -$100 Feeders/Cinwits $6 Each or 16 to 30 $1Q0
New Home — More than 30 eeders/Circuits (in add�ion�to New FeedersJCirwits — More Than 30 Feeders/Circuits '
above Feeders/Circuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) Reconneded FeederslCircuits
Feeders/Ci�i� $2 Each
Detached Garege or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere aL'i $35
New Feeders/Circuits ( ) � $6 Each New FeedersJCircuits ( ) � $6 Each
Other (Specify)
Rec:onnested FeedersJCircuits ( ) � $2 Each
Other (Spec�fy) Other (Specify)
Tota) (the fee calculated above or $35 muttiptied TOtal (the fee calculated above or $35 muitiplied Od
by the number of required inspedlon trips, by the number of required inspedion trips, „3 �
whichever is greater) whi�ever is greater) -�
Requests for Eleetrtcal inspectlon (REI) wlth a tee of $250 or tess expire 12 months from the flHng date. The eontractor must have �e work complete with�
the 12 morrth peNod or subm(t a�rother REI that ineludes the inspection fee for the uneompleted work. Inspecdon fees do not earry over from one EI t� �
another. P�
, A servlce eharge of S30 wf(1 be added for all d}shonored cheaks. �� �
I hereby certify that I inspected fhe electrical installatfon herein on fhe datea stated: For Departrnent Use O ly
Rough — In Inspection(s) Date �� �
� a� - �
F' nspectio Date �� N�. g�OO�
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This material can be made available in d(fferent forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (65'1) 297�198.
REI 02 (6/07)