P - 75422Minnesota Departrnent of Labor and Industry
443 Lafayette Roa��North
St. Paul, MN 55. ��5-4342
Phone: (651) � 5064
TTY/MRS: ( ) 297-4198
wHrw.electri .state.mn.us
Contr ctor Re uest for Electrical I
Date Rough-In Inspection Required?
11-16-08 Contractor Must Schedule All Roual
Address of Inspection - Street
150 ISLAND PARK DRIVE
Owner Name
JOHN WARD
Owner Telephone Number(s) - li
(952) 922-8758 ��;�v�
Contractor Name
PAUL STAFFORD
ContractorTelephone Number
(952) 927-7194
Contractor Authorized Sianature
#ion — One Family Dwellin /A
Yes Single Inspection Other Than Rouc
:ctions Contractor Must Schedule All Final
�('(�ai �{ ( S
FRIDLY
EXIT LIGHTING
-- 763 , S�f - � 3 `�l "
Contractor Mailing Addre
6225 CAMBRIDGE STREET
Contractor E-mail Address
jesse@paulstaffordinc. com
Contractor License Number
CA01713
Fee Calculation
New Home or Assoclated Structure
New Dwelling Service/Power Supply 0- 400 ampere @$35
New Dwelting Service/Power Supply 401 - S00 ampere @$60
------rd�r�wetiin��'�ersTCircuifs - - °- - - -- _ � _._.T
Other
- More than
To
�ers/Circuits - $100
(in addition to
Detached Garage or Other Associated Structure
New ServicelPower Supply 0- 400 ampere @$35
New Feeders/Circuits
Other (Soecifvl
( ) cLD $6 Each
ated Structure
❑ Ready Now
ms Q Will Schedule
� �� �1��
Job/Project Contact Person
JESSE ELLINGSON
Existing Home/Structure Remodel or Addltlon
New Servic�/Power Supply 0- 400 ampere �$35
New Service/Power Supply 401 - S00 ampere @$60
New/Eutended FeedersJCircuits - Up to 15 Feeders/Circuits
Feeders/Circuits $6 Each or 16 to 30 $100
New/Extended Feedene/rir%��ffc _ Mnrc� �n,�., an re�e�ir:..„.:.�
to 200 A
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New/Extended Feeders/Circuits ( ) � $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
� vtai �[ne ree caicuiatetl above or $35 multiplied Totel (the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection trips, $35
whichever is greater) whichever is greater)
Requests for Electrica I Inapectlon (REI) with a fee oi 5250 or less expire 12 moMhs f rom the flling date. The contractor must have the work completed w
the 12 moMh period or submft another REI that includes t he inspectlon fee for the uncompleted work. Inspection fees do not carry over irom one R �
another. �
A service charge of $30 will be added for all dlshonored checks.
I hereby certify that I inspected the electrical instellatlon herein on the dates stated� Fo D rtrn U
Rough - In Inspection(s)
nspection
,
This materlal can b�
TDD (651) 297-4198.
REI 02 (6/0�
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