P - 76754Minnesota Depa nt of Labor and Industry
443 Lafayette R North
St Paul, MN 55-4342
Phone: (651 84-5064
T1Y/MRS: 51) 297-4198 •
www.el ty.state.mn.us
Cont ctor Re uest for Electrical Ins
Date Rough-In Inspedion Required?
%�-� 1��6� Gontractor Must Schedule All Rough-In
RESIDENTIAL ELECTRICAL PERMIT BY CONTRACTOR
PERMIT # �� �
RECEIVED: � � � G 2 ��- 2�01
tion - One Famil Dwe{lin /Associated Structure
Yes Single Inspedion Other Than Rough-In: Ready Now
„-�c��� r.r�ntractor Must Schedule All Finai Inspedions ❑ Will Schedule
AOaress or mspea�vn — �ucC�
c� �� s N. ��o,�y ��. N� E-
Owner Name / �� l�
,�, � r �,��E� �
Owner Telephone Number(s) — Include Area Code(s)
��3�-S�I�$S�a—
Contredor Name Contrador Maitinc
E�j`LEiP ECEGTiPiG •iN�, f 8 /9
Contrador Telephone Number Contrador E-mail
76 3- yi3 - 1v 99
New Home or Associated Structure
New Dweliing 5ervice/Power Supp� 0� � ampere @ S3
CitylTo � �, w I County �
L� y ;� /7J�Q
Projed Description
�,q,►,� L ci��E �' 8���'�s
dress N • 553��
vvE�c 1'3L�'� N.�'_ — f,/,9„� L.��t'E� /yl
�r License Number I Job/Projeci Contact Person
�AD � z �-3
Fee Calculation
Existing Home/Structure Remodel or Addition
i New Service/Power Suppy 0— 400 ampere (c� S35 ��� �
New Dwelling ServicelPower Supply 401 — 800 ampere @ S60 New ServicelPower Suppy 401 — 800 ampere � 560
.�.,... n,.._u,,.,, Gee.�e.��r������r� New Feeders/Circuits — Up to 15 Feedets/Circuits
uD io 3u reeoers+�.uwiu -
New Home — More than 30 Feeders/Circuits (in addition to
�►,nvP� � 1 Feeders/Circuits Uo To 200 A(tD_ 56 Eai
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @ S35
Ne�y FeederslCircuits ( ) � $6 Each
Other
rcuits � S6 Each or 16 to 30 � 5100
- More Than 30 FeederslCircuits
rs/Circuits U� to 200 A(o� S6 Each
( �� ) Feeders/Circuits @ S2 Each � 2.$• �
Detached Garage or Other Associated Structure `
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ S6 Each
Reconneded Feeders/Circuits ( ) � S2 Each
Other (Specify)
TOtel (the fee calculated above or $35 muRiplied TOtel (the fee calculated above or $35 rnultiplied
by the number oi required inspedion trips, by the number of required inspectio� trips, S o
whichever is greater) whichever is greater) (p �
3-
Requests for Electrieal Inspeetfon (REI) wkh a fee of I250 or less expire 12 mo�ths from the filing date. The cotrtractor must have the work completed withln
the 12 month pe�lod or submtt another RE) that Includes the InspecGon fee for the uncompleted work. tnspectlon fees do not carry ove� (rom one REI to
another.
A servlce charge of S30 wlll be added tor all dishonored checks.
I hereby ceAily lhat 1 inspeded the eleclrical installaTwn herein on lhe dates �
Rough — In Inspection(s) Date
nspection
This materfal can b�
TDD (651) 297-4198.
REI 02 (6/07)
For vepartment use omy
Date I
z z �- � �'
:h as large print, Broille or on a tape. To request,
or