P - 76732Minnesoy De rtment of Labor and Industry �C� F F R 1 1 ZOOS
443 Lafa ette oad North
St. Paul, MN 155-4342 Q I 3�v
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Phone: (65 284-5064 �
TTY/MRS: 51) 297-4198 ' ���� ,.. Q� �� �
www.electri ty.state.mn.us
Contractor/Re istered Em lo er Re uest for Electrical Ins ection
Date Rough-In InspecHon Required? Yes Single Inspection Ofher Than Rough-In: Ready Now
Z� �' �' � Contrador/Em b er Must Schedule All Rou h-In Ins ' ns ContractodEm o er Must Schedule All Final Ins ions WU Schedule
Address of Inspection — Street City/Township County
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Owner Name Project Descrip 'on
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Owner Telephone Number(s) — Include Area Code(s)
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Contractor/Registered Employer Name Contractor/Registered Employer Mailing Address
SUBURBAN ELECTRIC, INC. 14800 28TH AVE N, SUITE 125, PL�YMOUTH; MN 55447
ContractodEmployer Telephone Numbe� ContractoNEmployer E-mail Address Electrical Utility
763-498-7215 �
Contracto,dEmployer Au zed Signature Contractor License Number Job/Project Contact I�erson
�---E ��- � ti�-� -�� CA02503 � ��J
� Fee Calr,ulatio n
Service/Power Suppiy 0— 400 aripere (c� $35 Techno{ogy System Devices ( )(d� 7� ¢ Each
Separate 3onding Inspections for Swimming Pools aid
Service/Fower Supply 401 — 80J ampere (c� a60 E ui otential Planes ( ) Q$35 Eac:h
Service/Power Supply Above 800 ampere �$100 Center Pivot Ircigatlon Booms ( )�$J5 Each '
j
Plus _ Electrical Drive Units Q$5 Each _ i_
New/Extended Feeders/Circuits Up To 200 A( ) Q$6 Each Luminaire Retroflt Modi�cadons ( )@ 25¢ E�ch
Feeders/Circtaits Above 200 A ( )@$15 Each Concrete-Encased Electrode hspection ( }(a� $35 Each
Investfgative Fee $70 O� The Total Inspecfion Fes,
Reconnected FeederslCirouits ( ! (� $2 Each
Whichever Is Greater U To $1,000
Ma�ufactured Home Park Lot Supply ( )@$35 Each Special Inspection Fee ( ) Hours ,� $80 Per Hour
Plus Mfles The IRS Mile e Rate of
Recreatlonal Vehide Sfte Supply Equipment Other
Circuits Ori inati in the E ui ment $6 Each
Street, Parking Lot, Lighting Standard ( )�$5 Each �e� � VOItS — Add the oombined servk:Npower eupply end teadedarouil tea to
rewlt in double ths regWu fee (dosa not apply W Nscuic eign �d ouwns lighting)
( ) New Multi-Family Dweilings (d3 $70 Each
Transformers Up to 10 kva ( )�$15 Each
With Up To 20 Feeders/Circufts
Transformers Over 10 kva ( )(d3 $30 Each ( ) Additional Circuits Above The 20 Allowed Per Unit
6 Each
Electric Signs and Outline lighting TOt81(the fee_calculated above or $35 muftipNed
Transformers/Power Su lies $5 Each by the number of required inspection trips, 3 S. S G
whichever is greater)
Requasts for Elactrical Inspecdon (REI).with a fae of 5250 0� loss ex�re 12 months from the flNng date. The coMractorlamployer must have the work
compkted within the 12 month peNod w submit another REI that includes the inspactlon fea for the uneompleted wo�lc. Inspaetlon fees do not carry over
from ona REI to anothar.
A sarvfe:a cha of:30 vWll be addad for aI1 dishonored ehaeks.
I hereby certtfy that I Inspected the electrical installatlon herein on the datea stated: For Dapartment Use Only
Rough — In Inspection(s) Dat+e
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Fi'at'inspection Date
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2 . �z e�— ��$�
This material can be made available in differont forms, such qs large print, Braille or on a tape. To roquest, call 1-800-342-5354 (DIAL-0U) Voice or
TDD (6S1) 297-4198.
REI 03 (6/07)