P - 75277Minnesota
443 LafayE
St. Paul, N
Phone: {6
- , �'1'YINlR�-
`�z �' �� ��Ylvdz��
�
�partment of Labor and Industry
;;Ktoad North
'S5155�4342
284-5064
51) 297-4198
y.state;mn.ws . :. _ :.. :; : -; ; , . ., . .:
Homeowner Re uest for Electrical ins ection
= Rough-Fn Inspeatitin �te�y�aiFe�� _ :✓. Yas-. := iasp�otian OtYier 7hen Rough En: :'_ � Read�;lVow -
�8 . H_oineowner M�st Se{�dt�te�il #� h-�n Jnspectilc�ns Homeowr�er AA�ust Schedule AlL Final lns ctiorts ❑ WiII SEPredul� ;
�-lnspec4ion:�Street t` oava'ts�
� � C'ttyfT ip : Gounty :
L;GF��ST`flR N� . � � .: - �#D���'. ;'" � : Af�lbf�A ` -
�ne . ,�. : _ . P�czject'i�s�`ccrllptibn . ;, .
; �
�I�K P��L K�LE = , . . . , ,, , _ .
..
-- ;- , -` �DD k.��� i.�w�1� W1�l.4..1NIT'� 2 �Lt�SETS
I$�stiot�e t�amber(s� :—#�ttstudal�� ��'`} '' ' Il`�fSF?���"�Q B`� �RIC�L�If I�tl.ITH �L{�5��`: L�C.�H`�:' �:
_� ) .
, . _
'fi 286Q ``. � `_ �. . � ,._ ����i�'�'��.� ���3 � I�A�t� R����'�'t���S �: � .�;
. . �: ,. .. . _
filing Address - Street _ _ Ciiy State Zip Code .
: pkite@kilefamily.net � XCEL
By signing this document, I certify that ! am the owne� as deflned by Minn. Stat. § 326.01 and will legaliy pertorm the electrical wark
Owner Signature
Fee Calculation
New Home or Associated Structure
New Home Senrice/Power Supply 0— 40d ampere @$35
�. ;�lew Home Service/Power Supply 401 — 800 ampere @�60
New Home Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home — More fhan 30 FeederslCircufts (in additinn to
Detached Garage or Other Assoclated Structure
New Service/Power Supply 0— 400 ampere Q$35
New Feeders/Circults ( ) @ $6 Each
Other lSnecifv)
Existing HomelStructure Remodel or Addition
New SeroicetPovuer Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended FeederslCircuits — Up to 15 Feeders/Circuits
( 1 ) Feeders/Circuits �$6 Each or 16 to 30 @$100
New/Fxiandwd Fwarirarc![:i►r�dfc _ AAnro Thcn �n Fenrlo.clr�sr,.�d
to 200 A
Detached Garage or Other Associatsd Structure
Wew Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
$6
' TOt11(the fee calculated above or $35 multfplied Total (the fee calculated above or $35 multiplisd
by the number of required inspection trips, by the number of required inspection trips, �3� �
whichever is greater) whichever is greater)
Requests for Electrlcal InspecUon (REI) with a fee oi �25A or less euplre 12 montha from the fllirtg date.'ihe owner must have the work complated wlthin the,�'`
12 moMh period or submit another REI that Includea the inspectlon fee for the uneompfeted work. Inspecdon fees do not cartq over from one REI to anothev:
A serolce char e of $30 wlq be added for all dishonored ct►ecks. �r
I hereby certlfy that I inspec4ed the electrical installatlon herein ort the dates staled: For Department Use Oniy
Rough — In Inspection(s) Date
�G ��,� �C'D �AI�,10 008
TDI} (65i) 297.4198.
RE101 (8107)
•,3,�/'-r.� .. cy fS I
�ch as large print, Bralile or ori a
or