P - 75666Minnesota Departryisnt of Labor and �dustry,
443 Lafayette Road North
St Paul, MN 55�55-4342
Phone: (651) 2E�-5064
TTY/MRS: ( ) 297-4198
www.electric .state.mn.us
Contra tor Re uest for Etectrical
Date Rough-In lnspedion Required?
��` � 1 �� Contractor Must Schedule All Rou
Address of Inspection - Street
b�%(� � �la za C �a�.re . -
Owmer Plame
Ca. � � �-�..� S
Owmer Telephone Number(s) - Include Area Code(s'
�) �1 � L `ec,i�r � C
�ontractor Telephone Number
6(L- �`�- Qlff '.�
Yes
. �•�
RESID�NTIAL ELEC�,CgAL v�R`�M� �Y CONTRA.CTOR
PERMIT # w— w w ' A AwwA
RECENED:
— One Famil Dwellin /Associated Structure
Single Inspection Other Than Rough-In: ❑ Ready Now
Contractor tdlust Sdiedule All Fina! Ins ctions ❑ Will Schedule
CitYlTownship County
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� Description ��� 1 G �,�frt
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Contrador Maiting Address
� � .�'9 � 5��' �-J'C .
Contractor E-mail Address
(1 +r, �► L' � C' C�.r. c, � Vl e�T' n.�„ I,
Contr�ctor License Number � -
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Fee Calculation
New Home or Assaciated.Structure
New DwelGng Servic�lPowrer Suppy 0- 40fl ampere �$35
New Dwelfing ServicelPower Supply 401 - 80� ampere @$60
to
New Home - More than 30
A
:-
to
Detached Garage or Other Associated Structure
New SenricelPobver Supply 0- 400 ampere @$35
New FeederslCircuits
Other
( ) � $6 Each
� � fVl�n►.,ce�o�cs � m �J SS�I ��1
Electrical Util'ity
r��fc,�
Existing Home/Structure Remodel or Addition
New Service/P�wrer Suppy 0-400 ampere �$35
Newr ServiceJPower Supply 401 - 8Q0 ampere �$60
N�w FeedarslCircuita - Uo to 15 Feeders/Circuits
3
- Mare Than 30
100
Each
�
R�,,,,C���,.�,�,,.,,,�,w � 2
`- ( % ) FeedersJCircuits @ $2 Each
Detached Garage or Other Associated Structure
New SenricelPorovver Supply 0- 400 ampere �$35
New Feeders/Circuits
Reconnested Feeders/Circuits
( )@$6Each
( ) � $2 Each
Tot31(the fee calculated above or $35 multipfied � Tohal (the fee calculated above or $35 multiplied
by the number of required inspedion trips, by the number of required inspedion trips, ���� v
vuhichever is greater) whidiever is greater)
Requests for Elec6�ical .inspectlon (REI) with a%e of $250 or less euptre 12 months from the flOng date. The eorrtraetor must have the work completed within
the 72 month period or submft another REI that includes the inspection fee for the uncompieted work Inspecflon fees do not carry ovet from one REI to
another.
A setvice charge of $30 wfll be added for all dishonored checks.
iZT � �c HFs �8� � /itV ���.�. . G -s�� Y
I hereby certify that I inspeded tl�e electrical instal on herein on thgdates stated: For Departrnent Use Only
Rough - In Inspection(s) //�� /(c']� ;j'`/r�i -° dr Date
� /1 . .l D 9 A���a V / ' /� � — .�� g �
Final Inspection v�
2�-:
This materiai can be made available in different forms, such as
TDD (651} 297-4198.
REI 02 (6/07)
or on a tape. To request,
or