P - 76235Minnesota De
aas �a�yett�
St Paul, MN
Phone: (651)
TTY/MRS: (6
of Labor and Industry
297-4198
Request for Electrical I
Rough-In Inspectlon Requfred?
%- I`- l� � � ConUactor Must Schedule A
Address of Inspection - Street
�S � I ri�,�,t�. l, d---e., c,� ��
Owner Name
T!� � l�-��� �� r ��,.0 n
Ovmer Telephone Number(s) - Include Area G
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Contractor Neme
Su.bu.rban �lG�fri�, ?�n�.
Contr�o[Tele�hone Number _ _ ___
7�3-�ta�-��s�
Contractor Authorized Signature
Yes
To6�: j-0- I I� � `�
(�,./V`�-C� I'�V/ �7
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I�C'D J U L 19 2007
— One Famil Dweliin /Associated Structure
Single InspecUon Other Than Rough-In: Ready Now
Contractor Must Schedule All Final InsaecUons �-�ltlill Schedule
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1�g00 Z8�' �AcVL' N• cS'ur�G �2�, PI ymOu�h S�K'!7
mtractor E-mail Address EI_ectrical Utllity _ _
Contractor License Number
Cp D� 503
Fee Calculation
New Home or Associated Structure
New Dwelling Serv(ce/Power Supply 0- 400 ampere @$35
New Dwelling Service/Power Supply 401- 800 ampere @$60
New Dwelling Feeders/Circufts
U to 30 Feeders/Circufts - $10U
New Home - More than 30 Feeders/Circuits (io addition to
above FeedersfCirc�its U To 200 A $6 Each
Other(Speciy)
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circutts
C�Z�Tfl
0 - 400 ampere @ $35
( ) @ $6 Each
Person
Deb
Extsting Home/Structure Remodel or Addition
{dew Servica/Power Supply 0- 400 ampere Q$35
IVew Service/Power Supply 401- 800 ampere @$60
New/Extended Feeders/Circutts - Up to 15 Feeders/Circuits
( ) Feeders/Cfrcuits @$6 Each or 16 to 30 @$100
Ne�..�c„�enrlad Faada,r:alrirr��ttc — Mere Than 30 Feedera/Clrcul
to
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New/Extended Feeders/Circuits ( ) � $6 Eech
Recronneded Feeders/Circuib ( ) � $2 Each
Totel (the fee calcwleted above or $35 mulUplied Totel (the fee celculated etrove or $35 mulUplied
by the number of required inspectlon trips, by the number of required Inspectlon trfps, �!J ���� �
whichever is greater) whichever is greater)
Requesffi for Electr1ea11nspecUon (REI) with e fae oi a250 or leas explre 12 mor�tha fram fhe flline date. The eontreatar must have the work wmpleted withln
the 72 moMh period or submR anather REI that inaludes !he Inspectlon fee for the uneompleted work. lnspecdon fees do not earry over irom one REI to
another.
A servlce eharge oi �30 wfll be addsd tor all dlshorrored chectcs.
I hereby certHy thet I inspected the electricel fnstaitetlon herein on the dates steted: For Department Uae Only
Rough - in InspecUon(s) Date
rms metene� cen a�
TDD (651) 287-4198.
REI 02 (6/07)
--��`�� 7 I
�ch as large pHM, Braille or on e tepe. To requeat,
or