P - 76887From: unknown Page: 2/3 Date: 10/3/2007 8:26:13 AM
Minnesota Department of Labor and Indus#ry
443 Lafayette Fioa vrth D[(`� O��' - 3 2��7
St, Paul, MN 55 342 RL� v
Phone: (657} 5064 ��
TfY/MRS: ) 297-4198 �'��(� " � ��/���—
www.elect ' state.mn.us
Contractor Re uest for Electrical !ns eCtion — One Famil Dw�llin /Associated Structure
Date Raugh-In Inspecrion Required7 Yes 5ingle Inspection Other than Rough-In: Ready Now
10-2-2007 �ntrackor Must Schedule Alf Rou h-In Ins ctions Contractor Must Schedule All Flnal Ins lons ❑ Will Schedule
Address of InspecHon - Street CitylTownship Courity
1323 HILI.WIND ROAb FR1Dl.EY ANOKA
Owner IVame Project Description
CARMA DOEGE EXT�ND EXISTiNG CIRCUfTS ARaUND NEW DOOR,
pwner Telaphone NumbeKs) - Include Area Code(s) FEED NEW OUTSIDE LIGHTS AND REGEPTICI.E
(612) 644�0'i48 -� Z��{� (v«�J FRQM EXISTING CIRCUITS
Contractor Name Contraetor Mailing Address
D1ER5 ELECTRIC lNC. BOX 340 HOWARD LAKE, MN 553A9
Contractor 7'elephone Number Contractor E-meil Address �lectrfcal Utility
(320) 543-37d0
Contractor Authorized Signature Contractor License Number Job/Project Contact Person
GA04977 TOM DIERS 612 868 4083
Fee Calculation
New Home or Associated Structure Existing Home/Structu�e Remadel or Addltion
New DweOing 3ervicelPower 5upply 0- 400 8nlpePe (c?� $35 New Servica/Power 5upply D- 400 ampere � S35
New Dwelling Servic:e/Pbwer Supply 401- B00 ampere (c� �60 New Servicelpawer Supply 401 - 90Q ampere � S60
-_ 1�Ee��y Fee��ers/Circuifs New/E:�ttBnded Feede[slCircuits - l!� � 15 FeeLlgtfC��4ultG
U to 30 FeederslClrcults -$�00 2 FeederslCi�cuits $6 Each or 16 to 30 ��00 ��
New Home - More than 30 FeederslCircuits (in addition to NewlExtended Feedera/Circuiis - Morp rngn 30 Feederv�Grcults
above Feetlers/CinCUits U 70 200 A $6 EaCft Feeders/Circuits U to 200 A $8 HaGh
Other (5peciTy) Reconrtected Feeders/Circuits
FeederslGirCUits $2 Each
Oetached Garage or Other Associated Structure Detached Garage ar Other Associated Structure
New Service/Power Supply 0- 400 ampere �$35 New ServlCelP0+N2� Supply �- 400 2mpef@ ��35
New Feeders/Circuits ( ) {� $8 Each (JewlExtended Feeders/Circuits ( ) � $fi Each
Other (5pecify) Reco�neCted Fe9derS/Cl�GUits ( ) � $2 EacN •
pti�er (SpeClfy) Other (Speclfy)
Total (the fee cala,lated above or S35 multlpl�ed TOt81(the fae calculated above or $35 multiplied
by the number of requfred inspectlon trips, by the number of requfred in6peCtlon b'IpS, $7� �
whichever is greater� whichever is greater)
��
Roquosts for EkcWcal Inepaetion (Req witl� a fae of iZSO or leae explre 1x months from !he Nling dato. Tha contraetor muet hevr the work cvmplete
the 12 moinn psfiotl or auDmit anotner REi tnat incrudes the Inapecdon iao for tho uneompl�tad work. Inspeefion fees do not carry ove� from ono REI to
anothor.
A eervlce charge oT $30 wlll b9 eldd9d (o� all tli9hdtOred CNecka.
I Mef9by cerliFy thet I inepeded the elecMcal inatelletbn herein on thp detCS Sitlietl; fo� Deptlrtrt19f1t U38 dnly
Rough - In Inspection(s) Date
-- %D� 3^��
Fin�l Inspection _ Date ;
� � 7
This mateH�l Can b ade �v�flflf�le in dlffereqt forms, such large pMnt, Brallle or on � tape. To requost, calt 1-800-342-5354 (DIA�-U6f) VoIC� ar
mo �ss�� xs7r�sa.
RE102 (810�