P - 75579Minnesaia DepaRment of Labor and Industry
443 Lafayette Road Np►1h
St. Paul, MN 55155,,4�42
Phane: (651) 2
TTY/MRS: (651 7�4198
www.eledri ' ate.mn.us
Contra or Re uest for Electricai I
Date Rough-In Inspedion' Required?
Contractor Must Schedule All Rou
Add�ess qt•I�s�ection — Street � _ � �� 1
Owner
�
� � �+'�� �
's) — Indude Area Cafe(s)
D �/
u
New Home or Associated Structure
New Dwelling Sarvice/Power Supply 0— 400 ampere (� $35
�
ection — One Famil Dwellin /Associated StructurE
Yes Single Inspection Other Than Rough-In: Ready Now
is edions Contractor Must Schedule All Final Ins dions Will Sch�u
� City/T ship County
� � `�i� Lsr. i�ND/��1
■� ��y ./ �
��� � � �: :,�, � � � � � �� . i
� . v�i�r �
E-maiLAddress Ele cal Util
� — �
r License ber Jo Projed Cc
�!� ��/,
Fee Calculat�on
New Darelling Servica/Power Supply 401 — B00 ampere � S60
s-
to
ea��..��....� i±�..�..e w. A1ho� A�cnwi��n�1 Cln�f_f11M
New Seroice/Power Supply 0— 400 ampere (� 535
New Feeders/Circuits ( ) � 36 Eaeh
r•
Existtng Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere Q 335
New ServicelPoarer Supply 401 — 800 ampere (c� �60
NeMr Feedars/Circuits — Up to 15 FeederslCircuits
FeederslCfrcutte 58 Each or 16 to 30 100
New FeederslCircuits — More Than 30 FaederslCircui�
( ) FeederslCircuits Cd� 32 Ea� I
Detached Garage or Other A�sociated Structure
New Service/Power Supply 0— 400 ampere (� 335
New FeedersJCfrcuits ( ) � 56 Ead�
Reconneded Feeders/Circuits ( ) � S2 Each
Total (the fee calculated sbove or S35 muitiplied TOtel (the fee calcxilated abova or s35 multiplied
by the number of required inspedian trips, by the number of required inspedion trips, A��O
whichever is greater) whichever is greater) ��:�'
Reqwsts tor ElacMul Inapectlon (REI) wlth s fea ot:250 or lass expire 12 months trom the filing date. The contraetor must have the work completed wlthin
tha 12 month (wrlod or submft mother REI th�t i�ludes the InspecUon tea for the uneompletad work. Inapectlon feas do not carry orer irom ons REi tc
anather.
X(y� _ �, y,; .�� A service charge of i3U rd0 be added tor aU dlahonored chaeks.
I hereby ceAiry that I inspaded Iha elacUical installation herein on the date.a atated: For Departrnent Use O
Rough — In Inspection(s) Date , �� � ��
Finallnspectio� �.< Date
�--.- �--1i-��
Thls matodal csn b� mad� �vallab(s In dlfferont tomis, sueh as larga pdnt,
TDD (8B1) 297-4198.
REI 02 (8/07)
�
�L.� �' U � � . �U�
or on a tape. To request, eall
or