P - 75360Minnesota DepartrneAt�of Labor and Industry /� �
443 Lafayette Road,h�orth �1, ��
St Paul, MN 551:�5-4342 � ��
Phone: (651) 2�4-5064 �
TTY/MRS: _S�1) 297-4198
Co ctor Re uest for Ele�trical Ins c��
» Rough-In Inspec6on Required? Yes
�i Contractor Must Schedu{e An Rou h-In ns ctio
1 d of Inspection - Street
�o � 3 7 �L'.��� ov� .%�v-e.. a�! �z _
Owner Telephone Number(s) - Indude Area Code(s) � i a 1
- 220 - � � P.
C�r�trador Name Contrador Ma
o er
Contractor Telephone Number Contractor E-r
'7% �2 r/l� F�ln�
tt£�ID�NTIAL �LECTRICAL PERMiT BY CONTRACTOR
PERi1n1T # �a g—�/ 7 C� S—
R�CEN�D: i�- %-d a�
— O�� �gmit D�rellFn �A�oc���d �t�ctt+rre
Single Ins�otion Other "C'han Ro�gh-In: Ready Now
Must Schedule All
��
Pro)ed a
��t'£:� �� 0' "' G -�C
� � � ��
Address
/� h��JS� �r ,�- � � � � w,
�ddress Eler�rical Utifityr
Contrado Author�ed Signature Contractor Licen� Number • I Job/Projec� Contact Person
,��'t✓��_ � � ��e/ � .
Fee Calculation
New Home or Associated Structure Exisiing Home/Struc�ure Remodel or AddifJon
Plew Dweqing Sera�ice/Power Suppfy 0- 400 ampere �$35 New Senrfce/Power Supply 0- 400 ampere @� $35
New Dwelling Service/Power Supply 401- 800 ampere �$6.0 New Service/Power Suppty 401- 800 ampere @$60
iVe�rDw�ffing Feed — -- - - Nev��ee�drer��/G' ' -- _
' � �n tn 3n FaPCiAre�cirn,Hs _$100 f % 1 FeederslCircwits (o� $6 Each or 16 to 30 lca $100 �
New Home -
A (o� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampera @$35
New Feeders/Circuits ( ) @ $6 Each
New FeedersJCircuits -
Eech
( �- ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New FeedersJCircuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
TOtal (tl�e fee calculated above or $35 multipGed TOtal (the tee calalated above or $35 multiplied
by the number of tequired inspedion trips, bythe number of required inspedion trips, �/,�
whichever is greater) whichever is greater) ()
Requests for Eleetr(cal Inspecdon (REI) with a%e of E250 or less e�cpire 12 mo� from the ftHng date. The coMraetor must have the work completed within
the 12 month period or submit atrother REI that inciudes the ins�on fee for the uncompleted work. Inspectlon f�s do not carcy over from one REI to
another.
A serviee eharge of $30 wfll be added for ail dishonored checks.
I Frereby certify that I inspected the etectriral installation herefn on the dat� stated: For Department Use Only
Rough - In Inspedion(s Date • ���� ��� �0�
�G ��-E3 �
Final inspec�tion Date �� /� `��
- �'/- e> � �
This material can be ma e avatlable tn dtfferent forms, sucb as large print, Brailie or on a tape. To request, catl 1-800-342-5364 (DIAL-DLI) Voice or
iDD (657) 297-4198.
REI 02 (6/07)