P - 75537Minnesota Departm: � t of Labor and Industry
443 Lafayette Ro ` orth
St Paul, MN � 5-4342
Phone: (65 5064
TTY/NIRS' 1) 287-4198
www.eie cdy.state.mn.us
Con ractor Re uest for Electrical 1
Date Rough-In Inspection Required7
,- - �e Contractor Must Schedule All Rou
Address of Inspection – Street
� `6 �1 t�n�1�o� �� � � E.
�er,�Name 1 n � L ��
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Contractor Name
AMERICAN ELEC7RIC INC
Contractor Telephone Number
(763) 566-5777
22950885
I IIIIII IIIII IIIII IIIII IIIII �IIII IIIII IIIII IIII IIII
tion — Or1� Famil Dweilin lAssociated Structure
yp,� (ngle Inspection O er an Rough-In: Ready Now
actions Contractor Must Schedule All Final Ins ections ❑ Will Schedule
C /Township C unty ��T.�� ^ ,�, .
e,
rojeat Des ription
�
U�� A,c3.r��
832 BELLVUE LANE, BROOKLYI�T�ENTEi�,-1VIN��4� ----
Contractor E-mail Address � Electrical Utility
JJLEWIS3@GMAIL.COM
nse Number Job/Project Contact Person
CA00162 JOHN LEWIS
New Home or Associated Structure
New Dwelling Service/Power Supply 0– 400 ampere �$35
New Dwelling Service/Power Supply 401 – 800 ampere @$60
New Home –
�cuits (in
To 200 ,
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere �$35
New Feede�s/Circuits ( ) @ $6 Each
Other
Calcula'tion
Enisting Home/Structure Remodel or Addition
New Service/Power Supply 0– 400 ampere @$35
New Service/Power Supply 401 – 800 ampere @$60
IVew/Extended FeederslCfrcuits – Up to 15 Feaders/Circuits
Fe�lers/Circults $6 Each or 16 to 30 $100
New/Extended Feeders/Clrcuits – More Than 30 FeederslCircuits
i Feeders/CUcuits Up to 200 A@$6 Each
� ) reeaers/circuits $2 Each �
Detached Garage or �ther Assoclated Structure
New Service/Power Suppiy 0– 400 ampere @$35
New/E�ctended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
0
Total (the fee calculated above or $35 muitlplied Votai (the fee calculated above or $35 multiplied
by the number of required inspection trips, by th9 number �of required inspection trips,
wh(chever is greater) whichever is reater)
Requests for Electrlcai Inspectlon (REI) with a fee of $250 or lese expire 12 months from fltlng date. The contractor must have the work completed within
the 12 month period or submk another REI that includes the inspection fee for the' unc mpleted work, inspectlon fees do not carry over from one REI to
/ anotF;er.
p �� 7 -�r� .� d A service charge of $30 will be added fo ell dtshonored checks.
/-1, 6 4
I hereby certify that I inspected the electrical instaltation herein on the dates stated: For Department Use Oni
Rough – In inspection(s) Da� �` 0��,�a p[�D a���, s, �oo�
11G e�
F�rfallnspection Date �
_ __�, - �c_ - –�i- -5 .-t�� — _ __
This mate�lal can be made available In different torms, such as Iarge print, Braille or on a tape. To request, cetl 1-800-
TDD (661) 287-4198.
REI 02 (6/07)
or