P - 75165A
__ Minnesota Depa ent of Labor and Industry
443 Lafayefte d North
St Paul, MN 155-4342
Phone: (651 64-5064
TTY/MRS: ( 1) 297-4198
vdww.elec�i '.state.mn.us
ContraGtor Re uest for Electrical fn
Date Rough-In Inspection Required?
� a- D o Contractor Must Schedule All Rou h-
Address f Inspection - Street
�bo ��y�o�.,� �� •
Owner Name
TN-I�Rp �� � L�E � s ���,t
Owner Tele one NumbeKs) - Include Area Code(s)
RESIDENTIAL ELECTRICAL PERMIT BY CONTR/�CTOR .
PERMIT # ��r?�� � °� i
RECENED: ��1 � �' R � S� 9f1P10
tion — One Famil Dweltin /Associated Structure
y� Single Inspection Other Than Rough-In: � Ready Now
�ctinns Contractor Must Schedule All Final Ins�ctions � Will Schedule
2;�(.�y � �-a,��
Projed Descxiption
� �%,�N ,���1� L - ��„Et �f��
�sh�� � �%Ly �ov>,.� Ar'-� �Ed�oo�
Contractor Name Contractor Maiting Address
�f� ����i i�� ° � �'6dve� ���- ���'
Contractor Telephone Number Contractor E-mail Address � Electrical Util'ity
�l03-'-�13- /d � �l
Contractor Authorized Signature Contrac#or Li�nse Number • Job/Projeci Contact Person
CAt� ��-�-3 � �Y1 � �K -
Fee Calculation
New Home or Assocfated Structure Existing Home/Structure Remodel or Additlon
New Dwelling Service/Power Sup ampere �$35 New Senrice/Prnaer Suppiy d�(� 0- 400 ampere $35
New Davel(ing Service/Prnaer Suppiy 401 - 800 ampere @$60 New Service/Power Supply 401 - 8Q0 ampere � 0
tivu,-r�,Air��� ��r�r.�rr„� - New Feeders/Circuits - Up to 15 FeederslCirca�its
Neuv Home -
Feeders/Circuits
Other
_
Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New Feeders/Circuits
Other (SRec[fy)
Other
( ) � $6 Each
( "�� ) FeederslCircwits �$6 Each or 16 to 30 �$
New FeederslCirc:uits - RAore Than 30 FeederslCircuits
( ) FeederslCircuits Ua to 200 A C� $S Eac
S �I
( � ) Feeders/Circuits @ $2 Each � /�d
Detached Garage or O�ther Associaied Structure
New Service/Powrer Suppiy 0- 400 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
Reconnested Feeders/Circuits ( ) @ $2 Each
Other (Specify)
Total (the fee cala�lated above or $35 multipiied TOtal (the fee calculated above or $35 multiplied �
by the number of required inspedion trips, by the number of required inspection trips,
%D° /
whichever is greater) whichever is greater)
Requests for EIe�Mcal Inspectfon (REI) with a%e of $250 or less expire 12 motrths from the ftling date. The contractor must have the work completed wfthin
the 12 month period or submR another REI that includes the inspection tee for the uncompleted work I�spectlon fees do not carty over from one REI to
another.
A service charge of $30 wfll be added for atl dishonored checks.
I hereby certify that I inspeded the elecMcal installation.herein on the dates stat�i: For Department Use Onfy
Rough - In Insped�i ,(s) Date
� l/��- �� `3 � S��iS
This mat'14-aI can bi
TDD (651j 297-4198.
REI 02 (6/07)
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fomis, such as large pri
or on a tape. ro request, can 7-BOO-a4z-5354 (o�A�-�u) vo�ce or