P - 75544�Minnesota D. artment of Labor and Industry
443 Lafayett �Road North
St. Paul, M 55155-4342
Phone: (65 2845064
TTY/MRS: 51) 297-4198
www.elect ty.state.mn.us
� Contractor/Re istered Em lo er Re uest for Electrical Ins ection
Date Rough-In Inspection Required? Q✓ Yes Single Inspection Other Than Rough-In: � Ready Now
06/04/08 Contractor/Em lo er Must Schedule All Rou h-In Ins ections Contractor/Em lo er Must Schedule All Final Ins ctions 0✓ �II Schedule
Address of Inspection — Street City/Township County
5179 SAINT IMIER DRIVE (,,f-� �'j — FRIDLEY ANOKA
Owner Name Project Description
JOHN P.lSDALL MASTER BATHROOM/LAUNDRY ROOM REMODEL
Owner Telephone Number(s) — Include Area Code(s) a� �-� �o�
(763) 572-0293
ContractorlRegistered Employer Name Contractor/Registered Employer Mailing Address
KLOOS ELECTRIC, INC. 4655 COUNTY ROAD 140, CHASKA, MN 55318
Contractor/Employer Telephone Number Contractor/Employer E-mail Address Electric:al Utility
(952) 448-6819 klooselectric@hughes.net
Cont ctor/Employer Aut rized Signature Contractor License Number Job/Project Contact Person
� CA01018 DAN KLOOS 612/750-1644
Fee Calculation
Service/Power Supply 0— 400 ampere @$35 Technology System Devices ( )@ 75¢ Each
Separate Bonding Inspections for Swimming Pools and
Service/Power Supply 401 — 800 ampere @$60
E ui otential Planes $35 Each
Service/Power Supply Above 800 ampere @$100 Center Pivot Irrigation Booms ( )@$35 Each
Plus Electrical Drive Units $5 Each
New/Extended Feeders/Circuits Up To 200 A( )@$6 Each Luminaire Retrofit Modfications ( )@ 25¢ Each
Feeders/Circuits Above Z00 A ( )@$15 Each Concrete-Encased Electrode Inspection ( )@$35 Each
Reconnected Feeders/Circuits ( )@$2 Each Investigative Fee $70 Or The Total Inspection Fee,
Whichever Is Greater U To $1,000
Manufactured Home Park Lot Suppiy ( )@$35 Each Special Inspection Fee ( ) Hours @$80 Per Hour
Plus Miles The IRS Milea e Rate of
Recreational Vehicle Site Supply Equipment Other
Circuits Ori inatin in the E ui ment $6 Each
Street, Parking Lot, Lighting Standard ( )@$5 Each OV@� EOO VOItS — Add the �mbined service/power supply and feeder/circuit fee to
result in double the regular fee (does not apply to electric sign and outiine Iighting)
Transformers Up to 10 kva ( )@$15 Each � ) New Multi-Family Dwellings @$70 Each
With Up To 20 Feeders/Circuits
Transformers Over 10 kva ( )@$30 Each ( ) Additional Circuits Above The 20 Allowed Per Unit
$6 Each
Electric Signs and Outline Lighting TOtal (the fee calculated above or $35 multiplied
( ) Transformers/Power Su�plies $5 Each by the number of required inspection trips,
- -- whicheVer is greateP) — -- - $70.5Q _
Requests for Electrical inspectlon (REI) wlth a fee of $250 or less expire 12 months from the flling date. The contractor/empioyer must have the work
completed wkhin the 12 month period or submit another REI that includes the ins�ction fee for the uncompleted work. Inspectlon fees do not carry over
from one REI to another.
A service char e of $30 wlll be ad ed for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on ttie dates stated: For Department Use Only
Rough — In Inspectio ) � � ��„ �.,�. e$.Date.
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��Final Inspection � �� p� � �� � � AI O' � 2008
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This materlal can be made available in different forms, such as large print, Braille or on a ta�. To request, call 1-600-342-5354 (DIAL-DU) Voice or
TDD (651) 297-4198.
REI 03 (6/0�