P - 75183Minnesota Depar�rilent of Labor and Industry
443 Lafayette d North
St. Paul, MN 155-d342
Phone: (651 84-5064
TTY/MRS: (651) 297-4198
vwvw.electricity.state. mn. us
Contractor Re uest for Electrical Ins
Date Rough-In Inspection Required?
12/31 /07 Contractor Must Schedule All Rou h-In
Address of Inspection — Street
1595 TROLL HAUGEN
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tion — One Famil Dwellin /Associated Structure
Yes Single Inspection Other Than Rough-In: � Ready Now
:ctions Contractor Must Schedule All Final Ins ections � Will Schedule
CitylTownship County
FRIDLEY ANOKA
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DAVID ASH �� � f� DEMO WIRING AND REFEED PER FIRE DAMAGE.
OwnerTelephoneNumber(s)—IncludeAreaCode(s) ��e,���J .� �Q�(.c r�a� �.��t��fe§
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Contractor Name Contractor Mailing Address
SOUTH SIDE ELECTRIC, INC. 9201 E. BLOOMINGTON FRWY, BLOOMINGTON, MN 55420
Contractor Telephone Number Contractor E-mail Address Electrical Utility
(952) 888-5500 e
�zed S' na re Contractor License Number Job/Project
. ; CA01695
�� Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply�— ¢0�0 amb�'re @$35
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New Dwelling Service/Power Supply 401 — 800 ampere @$60
Q � w av raeu��aia.u�ww - y
— More th n 30 Feeders/Circuits (in addition to
1 Feeders/Circuits Uo To 200 A C� $6 Each
Other
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
Mew FeedersJCircuits ( ) @ $6 Each
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits �
'3` Feeders/Circuits $6 Each or 16 to 30 $100 �
New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
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TOtal (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied -=
by the number of required inspection trips, by the number of required inspection trips, ��
whichever is greater) whichever is greater) � J'�
Requests for Electrlcal Inspectlon (REI) wlth a fee of $2b0 or less explre 12 months from the flling date. The contractor must have the work completed '�
the 12 month �rlod or submtt another REI that Includes the Inspectlon fee for the uncompleted work. Inspectlon fees do not carry over from one REI to
another.
A servtce charge of $30 wlll be added for all dlshonored checks.
I hereby certify th t I i pected the el�trical installation herein on the dates stated: For Departrnent Use Only
Rough n In p ion s Date
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/i" G1�l.�Y � ��— -- � /5 — c� �s �
Thls aterlal can be ma e avallable In dlfferent forms, such as large print, Brallle or on a tape. To request,
TDD (651) 297-4198.
REI 02 (6/07)
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