P - 75554Minnesota Depa ent of La�r and Industry
443 Lafayette Ro North
St. Paul, MN 5 342
Phone: (651) 2 5064
TTY/MRS: (65 � 297-4198
www.eledric' tate.mn.us
Homeowner Re uest for Electrical Ins
Date Rough-In Inspection Required? ❑✓ Yes Inspection OtherThan
6/19/08 Homeowner Must Schedule All Rou h-In Ins ections Homeowner Must Sch�
n
Ready Now
Will Schedule
Address of Inspection — Street CitylTownship County
6610 LUCIA LN NE FRIDLEY ANOKA
Owner Name Project Description
PAUL NEALY & STACY NEALY (BRAKE) OUTLETS AND CEILING LIGHTING INSTALLED FOR
OwnerTelephone Number(s) — Include Area Code(s) RENOVATION. WIRING INSTALLED FOR NEW
(612) 250-2372 (612) 812-6647 • �r,�-- ��ti � GARBAGE DISPOSAL. ,��j ;,,J�,11�10�•• �c�'s+�� Ni,h
Owner Mailing Address — Street City State Zip Code
6610 LUCIA LN NE �-3 �� FRIDLEY MN 55432
Owner E-mail Address Electrical Utility
BRACYSTAKE@YAHOO.COM XCEL ENERGY
By signing this docum�nt, I certify that I am the owner as defined by Minn. Stat. § 326.01 and will legally perForm the electrical work
a
Fee Calculation
New Home or Associated Structure
New Home Service/Power Supply 0— 400 ampere @$35
New Home Service/Power Supply 401 — 800 ampere @$60
Up to 30 Feeders/Circuits - $100
— More than 30 Feeders/Circuits (in addition to
) Feeders/Circuits Up To 200 A Cc� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
Other
Other
0 — 400 ampere @ $35
( ) @ $6 Each
Existing Home/Structure Remadel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Fxtended Feeders/Circuits — Up to 15 Feeders/Circuits
( ) Feeders/Circuits @$6 Each or 16 to 30 @$100
New/Extended Feeders/Circuits — More Than 30 Feeders/Cira�i
( ) Feeders/Circuits Up to 200 A $6 Each
Reconnected Feeders/Circuits
( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New Sennce/Power Supply 0— 400 ampere @$35
New/F�ctended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection trips,
whichever is greater) whichever is greater)
. .��
Requests for Eledrlql Ir�pectlon (REI) wtth a fee of $250 or I�s explre 12 manths from the ftltng date. The owner must have the work completed withln the
12 month �rlod or submlt another REI that includ� the Inspectlon fee for the uncompleted work. Inspectlon fees do rrot carry over from one REI to another.
A service cha e of $30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: � For as�rtr�Qn Use Only
Rough — In Inspect�s) '/' �_ Date �+� � � c��� � _ ���
s n e /� .'/ .� ` Yv
Final Inspection � n � p�� � h�-� t�N �� 200�
,l°� , 1'(C �l
Thls material can be made avallable In dlfferent forms, such as large print, Braille or on a tape. To request,
TDD (651) 297�198.
REI 01 (6/07)
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