P - 75266Minnesota De nt of Latror and lndustry
� 443 Lafayette , oed North
St. Paul, MN! 155-4342 g/S y�O ��
L
Phone: (85 2845084 . �
TTY/MRS: 51) 297-4198 �
www.el .state.mn.us
Contractor/Re istered Em lo er Re uest for Electrical Ins ection
Date Rough-In Insp�Hon Required? Yes Single Inapectlon Other Than Rough-In: Ready Now
3' ��� � D Contracxqr/Em r Must Schedule Ap Rou h-In Ina ona ContrectcdEm lo r Must Schedule AU Flnal Ina ons 1MU Schedule
Address of Inspectlon — Street City/Township County
S �%w . re v- S 1�� " e, oK�
Owner Name Project DescripUon •
Gl�v�v� Wie�v���!-F �'IeLf�ie�/ ,�r fi��ej�/��Q i�rfe��.
Owner Telephone NumbeKs) — Include Area Code(s)
� co3ti � � �. � �—I �
Contractor/Registered Employer Name ContractaNRegistered Employer Mailing Address
SUBURBAN ELECTRIC, INC. 14800 28TH AVE N, SUITE 125, PLYMOUTH, MN 55447
ContractodEmployer Telephone Numbe� ContractoNEmployer E-meil Address Electrical Utllity �
76�-495-�� - - - _ - .
Contractor/Employer Authorized Signature Contractor License Number Job/Projed Contact Person
lv � � CA02503 ��� ��Zo v9v. �� e �
� Fee Calculation
Servlce/Power Supply 0— 400 ampere (� $35 Technalogy System Devices ( )� 75¢ Esch
Service/Poarer Supply 401 — 8�0 ampere (c3� $BO Separate 9cmding Inspectlons for Swimming Pools and
E ui tentlel Planes $35 Each
Service/Power Supply Above 800 ampere @$100 Center Pivot irriga8on Booms ( )(u3 $J5 Each
_ _ _ __ Rlus ElectricalArivE Uniis $5 Each_
New/Extended Feedera/CUcuits Up To 200 A( ) c� $6 Each Luminaire Retraflt Modlflcatlons ( ) aQ 25¢ E�ch
Feeders/Circuita Above 200 A ( )@$15 Each Concrete-Encased Electrode Inspectlon ( )@$35 Each
Reconnected FeederslCircuits ( �,� $2 �� InvesUgaHve Fee $70 Or The Total Inspectlon Fee,
Whichever Is Greater U To $1,000
Manufaciured Home Park Lot Supply ( )@$35 Each Special InapecUon Fee ( ) Hours �$BO Per Hour �
Plus Miles The IRS Mqea e Rete of
Recreational Vehide S(te Supply Equlpment Other
Circuits Od IneU in the E ui ment $6 Ear.fi
Street, Parking Lot, Ughtlng Stendard ( )(a� $5 Each Over 600 Volb — aad ue �mnu�ea �oer� m�y ena r�n� ree m
�e�lt tn dauble tl�e r�d� fee (d�s �rot �ply to eleafatc sign m�d auNrre q8�9)
( ) New Multl-Family Dwellings (aU $70 Each
TransfoRners Up to.10 kva ( )�$15 Eech
. Vdtth Up To 20 Fe�ers/Cir�ailk
Transformers Over 10 kva ( � )@$30 Esch ( ) Additlanal Circuits Above The 20 Allowed Per Untt
Eech
ElecMc Signs and Outline UghUng TOtel (the fee, calcul�t� above or $35 muidpli�
Trensformers/Power Su lies $5 Eech by the number of requlred inspectlan trips, js SD
whichever (s greater)
Rsquests tor Elect�eal Ins�ctlon (REI).unith a fee of �2250 or lesa expfre 12 months from tha fl8ng date. The aontraatodemplo�rar must heve the arork
compteted wlthfn tl�e 12 month �riod or eubmR another REi that d►ciudee the Ins�ctlon tee for tl�e uncomplated work. Ir��an fe� do Ro! cany over
iram one REI to another.
A servFae ah e ot wip f� added for ell diahonbred cheaks.
1 hereby certlfy that I inspeated �a eleaMcal Ina�lladon hereM on the datea stated: For DepartmeM Use Only
Rough — In InspecUon(s) p�e �� �� 1 J� �� �Q ��. n 2000
� 1 1' O
Final Inspecbon Date
� ��=v�
This rrretariel ean ade avallable in diHere�rt Torms, such �s ler�e pr�nt, Breflle or on a tape. To requast, call 1-600�42-53 (DIAL-0L� Volee or
TDD (8S1) 287�198. "
REI 03 (e/07)