P - 75494'
Minnesota Depa ent of Labor and lndustry
443 Lafayette R d North
St Paul, MN 55-4342
Phone: (651 64-5064
TfY/MRS: 1) 297-4186
w�vw.el .state.mn. us
Cont ctor R uest for Electrical Ins e
��c� Rough-In lnspeciion Required? �
�'1 /`D � Contractor Must Sd�edule Atl Rou h-In Ins
Address of Inspec�ion - Street
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Owner Name ��
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O�aner
C.C11�"df�0� i�BlilE
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Plumber Contractor
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Yes
RESIDENTIAL ELECTRICAL PERMIT BY CONTRACTOR
PERMIT # �°� � G ��-PO
RECENED:
— One Famil Dwellin /Associated Structure
Single Insped3on Other Than Rough-In: � Ready Now
Contractor Must Sc�edule All Final Ins ctions .�--vvill Schedule
ICityfTownship� Coun�� t �
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:.o ctor Author¢ed Si ture Contrador Li�nse Number • Job/Project Contact PersQn
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Fee Galculation
New Home or Assocfated Structur� Existing HomelStructure Remodel or Addition
Plew Dwelf'mg Service/PowBr Supply 0— 400 ampere �$35 New 5enric�/Power Supply 0— 40D ampere �$35
New Dwelfing Senric�:/Power Suppy 401 — 8D0 ampere �$60 New Service/Prnroer Suppfy 401— 8D0 ampere �$60
wle... I'l...allinn Cen.ier�lf irra�i:� -- --- � Alcw Fmriarc7P`_`�rra�ifc � iln �fn 1.����mrTnrcT_irr��S4�c- -- .
New Home — More than 30
abuve) ( ) Feeders
Other (SpecfN)
_
To 200 A C� $6 Each
Detached Garage or Other Assoclated Structure
Idevv ServicelPower Supply 0— 400 ampere �$35
Idew Feeders/Circuits ( ) � $6 Each
Other (Specify)
Otfier
) Feeders/Circ:uits � $6 Each or 16
eders/Circuits — More Than 30 Feede
�) FeedersiCircuits Up to 200 A
ected Feeders/Circuits
( j ) Feeders/Cira�its @ $2 Each �o
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 4D0 ampere @$35
New FeederslCircuits ( ) @ $6 Each
Reconnested F�ders/Circuits ( ) @ $2 Eadi
`��
Total (the fee calculated above or $35 multipfied Total (the fee calculated abova or $35 multipli�l �
by the number of required 'mspedion irips, by the number of required ins�dion trips, �
whichever is greater) whichever is greater) �.�
Requests for Electrical Inspectlon (REI} wkh a fee of $250 or less exptre 12 montl� from the ftHng date. The contractor must have the work completed wlthir�'
the 12 montl� period or submit another REI that includes the inspecdon fee for the uncompleted work. Inspedion fees do not carry over from one REI to �
another. ��
A service charge of $30 will be added for aq dishonored ch�ks. �� ��
I herebY certiN that I insaeeted the ei�l mstallation her�in on the dates stat�: For Departrnent Use Oniy
Rough - In I
Inspection
This mate�fal can tii
iDD (651) 297-4196.
REI 02 (6/07)
L„G � 1%l -+�l� Date
� � �g'�
Date
_����
lifferent forms, such as larq�
�
t�d'� � �
RE AUG 19 200�
or on a tape. To request, call 1-B00-342-;
Vofce or