P - 75534Minnesota Depai
443 Lafayette Rc
St Paul, MN 55,
Phone: (651) ?�
TTYlMRS: (6 ) 297-4196
.state.mn. us
:or Re uest for Electrical Ins
Rough-In Inspection Required?
Contractor Must Sc�edule All Rouah-In I
Labor and Indusfi�y
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Addre�,s of Inspec�ion — Street
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Owmer Plame
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Owmer Telephone Number�s) — Include Area
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Corrtract�r Name
/IP0�7�1 Se0 6 E«-cz�e�
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Contractar Authorizerl Siqnature
Contractor
RESIDENTIAL LEC ICAL P RMIT BY CONTRA.CTOR
PERMIT # �1.+'�� � ld � � �' �
RECENED: �_ i i i � 1� �nn�
tion — One Famil Dwellin /Associated Structure
y� Singie Insper.tion Other Than Rough-In: [] Ready Nowr
:cbons Contracfor Must Sr,�edule All Firtal Inspecfions �VIfiU Schedule
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�s���r pvc �iv��� �ox�s �o� ���
P�eoT�eTC� oyr�E>s, sEP�r� r�ra���ey
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Contrador Licens� Number •
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Fee Calculation
New Home or Associated Structure
. New Dwetfing Servit�/Prnaer Suppy 0— 400 ampere �$35
New Dwelfing Servi�/Powrer Supply 401 — 800 ampere @$60
Up to 30 FeederslCira�its -
— More than 30 �eeders/Circ�its (in addi�on to
1 Feeders/Ciraifts Uo To 200 A fo� $6 Eai
Detached Garage or Other Associated Structure
New Servit�lPower Supply D— 40� ampere @$35
New FeedersJCircuits ( ) � $6 Each
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:c� Coritact
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Existing Home/Structure Remodei or Addition
Plewr ServicelPovuer Supply 0— 40D ampere @$35
New Servic:�/Power Supply 401— 800 ampere �$60
New Fuc�lnarcltskn�iic _ I ln +n 1r, Fmricrel� _:ra�a�i+c �-- -- f
( ) Feeders/Circ�its � $6 Each or 1
New Feeders/Circuits — AAore Than 30 Feec
( ) FeederslCircuits Up to Z00,
Reconnected FeedersJCircuits
Detached Garage or Other Associated Structure
New Service/Prnver Supply 0— 400 ampere �$35
New Feeders/Circuits
Reconnested Feeders/Circuits
( ) @ $S Each
( ) @ $2 Each
Toi�l (the fee calculated above or $35 muttipl'ied Total (the fee calailated above or $35 muitipfied do
by the number of required inspedion trips, by the number of required inspedion trips, �°�
whichever is greater) whichever Ls greater) � fi��.✓
Requests for Electrieat Ins�on (REI) wfth a%e of $250 or Iess expire 12 montt� fro the ftting date. The corrtractor must have the woric compteted wifhin �
the 12 moMh period or subm(t arrother REI that indudes the inepection fee for th ncompleted worlc. Inspecdon fees do not carry ovet from one REI t�
anothe � o�
A service charge of $30 witl be for ail dishonored ch�ks.
I hereby certify that I inspected the el�trical instal� herein on fhe dates sta : For Department Use Only
Rough — In Inspection(s) Date
U �!,� G �' �
This materfal can be made avaflable fn different forms, such as large print, Braille or on a tape. To request, cali 1-600-342-53b4 (DIAL-DL1) Voice or
TDD (651j 297-0�198.
REI 02 (6/07)