P - 76966Minnesota Dep nt of Labor and Industry
443 Lafayette ad North
St: Paui, M 5155-4342
Phone: ( 284-5064
TTY/M (651) 297-4198
� www. ricity.state.mn.us
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�,�p AUG - 7 2007
� Homeowner Re uest for Electrical Ins ection •
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Date Rough-In Inspection Required? Yes inspection Ofher Than Rough-in: Ready Nova
r 4 y / t�� Homeowner Must Sc��edule All Rou h-In Ins ions Homeowner Must Schedule All Final Ins ctions V1nll Schedul�
A dress of Inspection — Street CitylTown�r,ip Coun � �
� l 61 �'';,,; � �� �(J�= ��.�%,� -� o S
�'er Name Projed Descxiption ' '
� �, e � C� .-, !,�) f,,, c� ��--� ��- �.�n
Owner Telephone Numbens) — Include Area Code(s) V" �1 ix" ��� � �. _ r
7(�— Sc� Z— � Y 6 i 6.�1— Z g3--3 z z J—
�er Mailing Address — Street City State Zip Code
6/ T-,.: .,. k 1 F N� �''.: �,� �� ,� ' %y v .r�s-v3 z.
Owner E-mail Address / Electrical Utility
Seo�C�^, �7 � G.�4��►s. �,Cor, '
By sgning this document, I certify that I am the ovmer as defined by Minn. Stat. § 326.01 and will legally pertorm the electiical work
Owner S' nat
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Fee Calculation
New Home or Associated Structure
New Home ServicBfPower Supply 0— 400 ampere @$35
- -"�TJ�ew Hotne�etvicelPoMiar ��t'='"89��n►pe�e�
�V w ov reauoisra.nwns'
— More than 30 Feeders/Circuits (in addition to
Detached Garage or Other Associated Structure
New Service/Povver Supply
New FeederslCircuits
0 — 400 ampere @ $35
( ) � $6 Each
Existing Home/Structure Remodel or Addition
New Service/Power Supply
0 — 400 ampere Q $35
r�
New Feeders/Circuits — Wp to 15
16to30Cd�S100
— More Than 30 Feeders/Circuits
rs/Circuits Ua to 200 A Cdt S6 Each
( ) FeedersJCircuits $2 Each �
Detached Garage or Other Associated Structure
New 5ervice/Power Supply
New Feeders/Circuits
Reconneded Feeders/Circuits
Other (Specify)
0 — 400 ampere (d� $35
( )�$6Each
( ) (d1$2 Each
a�30-5
Total (the fee calculated above or $35 muldplied Total (the fee calculated above or $35 muRiplied
by the number of required inspection trips, , by the number of required inspection trips,
whichever is greater) whichever is greater) .
Requests fw Electrleal Inspection (REI) with a fee of 5250 or less ezpire 12 morrths from the filing date. The owner must have the work completed within the
12 month perfod or submit another REI that includes the i�peetion fee for the uncompleted work. lnspectlon fees do not carry over from one REI to another. .
A serWce cha e of s30 will be added for all dishonored checks. •
I hereby �rtify that 1 inspected the elecUical installatbn herein on dates stated: For Department Use Only
Rough — In Inspedion(s) Date
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This material c1�iy�eASde available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Vofce or
TDD (657) 297-4198.
REI 01 (6/07)
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ELECTRIt:�►ri�1SP�ECT10N3 >�,, PERMIT NO.�-' �- o f y;`-v
��. CORRECTION O���R _� DATE � ` .�� �= �'
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° InstaNerofWi�ing G�`"��`� � ...:; >,.
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, OwnerlOcatipeM �"'� C ff l�! �� ; ��,L r�
` Property Addross /iJ � �P % ��! ' � � / f.l''t ZP f "rl � ���Y.
The followfng items are daviaUons from the acceptiad apandevds of construction at the above descrihed
. Premisas. Numbers after ee�h item are applkable Natlonal ElecMcal Code �SecNone: .
�� � Q�,, S j�/� �'• G - � $ �"��
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�.( ;� C a ��-� � h /E. 5 � '�< <"'` r� '
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, � J---�q f.�Zi,,., -u� iT �i `'Tr� '� C �/�,,`-_7 �/ctt�_'d e,7 . rt �
CtRF�C! 1�N 1101� �i�C�11C�M'fld:
� NaMfy Msp�c�or 4oF r�insp�ctlon b�tors coy�ring wiriny.
���INesp�cdon will b� mad� at�n�xt insp�ation.
�`$ipn and �um this iorm to I wh�n cornctions M�w b�sn maeN but no I�br'",.
th�n ID�bJ
Ro�ert Clauson
1588 E. �e�ctant Ave.
M�pbv�tood, M N 55109
;�
Siynature of InsE�ller
D�e a compliance
cau s5�-anae+
, MondE
Ha:e.k„3,...rc.�.r�s.�. .. 4.,�i'.u.�, .
�5 for Reinspection - 7:00 - 8:30 a.m.
y - Friday except holidays.
'RC-01 . .