P - 76236��
Minnesota DeP�►�► ��'nt of Labor and Industry
443 Lefeyette Ra�d North
S't. Paul, MN 5, 342
Phone: (651) 064
TTY/MRS: (6 ) 297-4198
www.electri .state.mn.us
Contractor Re uest for Electrical Ins
Date Rough-In InspecUon Required?
�� `�' "�� � Contractor Must Schedule All Rou h-In
Address of Inspection — Stneet
--� � ���� %= 9 � G'���. `` � ,!�� �-
Owner Neme .
����'���� ���� �/�� l��l ��-,
Ovmer Telephone NumbeKs) — Include Area Code(s)
;�%� l� I � - d�.-'�`��a
N Contractor
Yes
— One
To6 � : �.� j i �l��
�,C�a�-C�r��c�
REC'D ..�uL i 9 2001
�ellin /Associated Struc#ure
� Than Rough-In: R�ady Now
ule All Ftnal Inspectlons LrJ VUill Schedul
�— e� I �� �'��� I
Projed Descriptlo
� "�
,�������� «� � � �';`�,- �. �'1..�:U�-
-� � 1.
L>� �� �:�� (.�,��,� °at.,-�--r i°�,r�-�%��.
Contractor ame � •-._.....o - ------ .
Su.bu.rbQa'► �ICGfrit, ��• 1��OD Z8'�' �rV� N. �'ur�G �ZS, PI ym4u�'h s�17
Contrador Telephone Number Contractor E-mail Address ElecMcal tJUI(ty
7�r3-4�-iV�'�! -- - - - - - - -- - --
thorized Signature Contractor License Number Job/Project Conted Person
C� 0� 503 �eb �
Fee Calculation
New Home or Associated Structure Existing HomelStructure Remodel or Additlon
New Dwelling Service/Pouver Supply 0- 400 ampere @$35
To 200 A
Detached Garage or Other Assoclated Structure
New Service/Power Supply 0- 400 ampere a('� $35
New.Fepders/Circa�its ( ) (a� $B Eech
New Service/Power Supply
Neu��ervicelPower Suppty
0
0 -400 ampere (c� $35
401 - 800 Hmpere � $60
- Up to 1b FeederslCircui�
s Each nr 16 to 30 re.l $900
Each
Detached Garage or Other Assoclated Structure
New 3ervics/Power Supply 0- 400 empere �$35
New/Eactended Feedere/Circutts ( ) � $6 Eech
e
Re�nneded Feeders/Circults ( ) @ $2 Eech
Totel (the fee calc�lated above or $35 mulUplied Totel (the fee c�lculeted ebove or $35 multtplied
by the number of requtred Inapectfon trips, by the number of required Inspe�Uon trips, (� ���
whichever is greater) wrhlctrever Is greater)
Re�uaets ior EleoMoallnspecUon (REI) with e tee oi 5280 or less expUe 12 months trom the ftling dele. TAe aoMractor muat have the work �ompleted withln
the 12 moMh peMod or aubmit another REI that Includes !he inspeatlon tae for the uneompleted work. lnapedlon taes do not certyr over irom one REI m
another.
A aervice charge of 530 wIU be added tor ell dlshorrored cheeks.
I herebvi certlN tl�et I insnected tFre eler�ricel ir�stelletlon hereh� on tlte dat� s�ted: For Depertment Use Only
Rough — In Inspe�tion(s)
Thls mateyal cen be made avallable in
TDD (6S1) T.97-4198. .
REI 02 (8/07)
Date
2���� �
such es lar9e pr�nt, Bratlle or on e tape.
or