P - 75714Minnesota Depa ' nt af Labor and industry
443 Lafayette ,,' ad North
St Paul, MN 5155-4342
Phone: (65 284-5064
TTY/MRS' 651) 297-4198
w►aw.ele ciry.state.mn.us
Homeowner
Daie Rough-In Inspection Required?
7�-�" —�� Homeovmer Must Schedule All Rc
Address of Inspection — Street
��� OUe��OH �r %U[
11(��� t�r�� er �t
Owner T Isphone Number(s) — nGude A�
7��- ��2-04��
Owmer Mailing Address — Street
�(o O O � e� �� �UC-
Owner E-mail Address
�C��7 �C� l �
REC'D J U L 3 0 001
uest for Electrical Ins
� y� inspection Other Than
n Ins 'ons Homeowner Must Schedule All Fnal
Cit�rlTownship Coi
I�,-; �1 �
Projed Description
.0 l�� ��-;�, � �►r
V�-� � C�� d � �o ��-�
c�y
`� ��2.
�i ubiity.
U Ready Nowc
�pections ❑ V�ill Schedule
yV�-�. o k v�-
re -�Ks�. � ��
1�IN SS4 32
By signing this dacx�ment, I certify that I am the ovmer as defined by Minn. Stat § 326.01 and will legally pertorm the eledrical work
New Home or Associated Strvcture
New Homs Service/Power Supply 0— 400 ampere �$35
New Home Senric�/Power Suppy 401 — 800 empere �$60
New Home FeederslCircuits
New Home — More than 30
Other
30 Feeders/Circuits -
;irc�its (in addidon to
"0 200 A (cD $6 Each
Fee Calculation
Detached Garage or Other Associated Structure
New Servics/Power Supply 0— 400 ampere a@ $35
New Feeders/Circuits ( ) @ $6 Each
�
Exlsting Home/Structure Remodel or Addiilon
New Service/Pouver Supply 0— 400 ampere @$35
Newr Servic�/Power Supply 401 — B00 ampere @$BU
New Feeders/Circuits — Up to 15 Feeders/Circuits
FeedersJCircuits $6 Eac� or 16 to 30 $700
�Nevn FeederslCircuits — More Than 30 Feeders/Circuits
( ) Feeders/Circ�its Up to 200 A(rD_ $6 Each
Detached Garage or Other Associated Structure
New Senrice/Power Supply 0— 400 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
Reconneded Feeders/Circuits ( ) � $2 Each
�
Other (SpeCtfy) u[ner l�Pe�r►YI . �'�� ,�U
Total (the fee calculated above or $35 multiplisd Total (the fee calculated above or $35 multiplied
by the number of required inspedion trips, by the number of required inspection fips, n �
whichever is greater) whichever is greater) v� �� L,
Requests for Electrical InspecNon (REI) wtth a fee of $250 or less explre 12 months from the 81ing date. The owner must have the work completed within the
12 month period or submit anotF�er I2EI that fncludes the I�pecUon fee for the uncompleted work. Inspectian fees do not carry over from one REI to another.
A servlce c e of $30 will be added for all dishonored checks.
I hereby certify that 1 InspeGed the electrical installatlon herafn on tlre dates stated: For Department Use Only
Rough — In Inspedion(s) Date
Final
�, l�. f�!'� ��,�,��.�___-. � 3�- G% I
This ma al can be ma e avallable in different forn�s, sueh as large pr(nt, Braille or on a tape. To request,
TDD (651) 297-4198.
REI 01 (6/D�
or