P - 76673Minnesota Dep ent of Labor and Industry
443 Lafayette ad North
St Paul, M 5155-4342
Phone: (6 284-5064
TTY/MR (651) 297-4198
www.ele 'city.state.mn.us
Con actor Re uest for Electrical
Date Rough-In Inspection Required?
� � Contractor Must Schedule All Rou
Ari rwcs f Incnwrlinn — StrPet
Name
- Indude Area Code(s)
�d� � ��i'�/ia
Contractor Name
KATH ELECTRIC
Contrador Telephone Number
(651) 484-3325
�ignature
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�C'D N 0 V 15 2007
�tion - One �amif Dwellin /Associated Structure
Yes ��ngle Inspedion Other Than Rough-tn: Ready Now
sdions Contrador Must Schedule All Final In ections Will Schedule
Ci lTownship County
Projed Descripti
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Contrador Mailing Address
3096 RICE STREET / LITTLE CANADA, MN 55113
Contractor E-mail Addr�ess Electrical Utility
kei�hwilliams@kathfuel.com
Contractor License Number Job/Project Contad Person
CA00980 KElTH WILLIAMS
Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New DwelGng Service/Power Supply 0— 400 ampere (ds $35 New Service/Pawer Supply 0— 400 ampere (� $35
New Dwefling Service/Power Supp{y 401 — 800 ampere �$60 New Service/Paiuer Supply 401— 800 ampere (83 $60
New Dwellina Faeders/Ci�wrts NewlE�ended Feeders/Circuits — Up to 15 Feeders/CirCUits
— More than 30 FeederslCircuits (in addftion to
1 FeederslCircuits U� To 200 A(� $6 Each
Other
Detached Garage or Other Associated Structure
New Service/Paiver Supply 0- 400 ampere (� $35
ivew Feeders/Circuits ( ) � $6 Each
- More Than 30 Feeders/Ci
ts Uo to 200 A l� S6 Each
( ) Feeders/Circuits � $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere �$35
New/�dended FeederslCircuits ( j � $6 Each
Reconneded Feeders/Circuits ( ) (� $2 Each
Total (the fee calculated above or $35 mul�Plied Total (the fee calculated above or $35 multiplied
by the number of required inspedion trips, by the number of required inspedion trips, ��
whichever is greater� whichever is greater) ..�i
Requests for Electrical Inapection {REI) with a fee of 5250 or less expire 12 months from the flling dabe. The cor�tractor must have tAe work compteted within
the 12 month period or submit another REI that includes the inspection fee tor tl�e uncompleted work. lnspeclion fees do not carry over trom one REI to
another.
A service charge of �30 w111 be added for all dishonored checks.
I hereby certiTy that I inspected the electrical installation herein on the dates :
Rough - In Inspection(s) Date
Final Inspection _ ..- x Date
�,` �- C: �--_.� r lJ' �v
This material can be made available in differeM fortns, such as large �
TDD (661) 297-4198.
Braille or on a tape.
For oeparut�en[
or