P - 76647Minnesota Deparl�nent of Labor and Industry
443 Latayette R d No�th
St. Paul, MN 5 55-4342
Phone: (651) 5064
1"TY/MRS: (6 ) 297-4198
www.eledri ' state.mn.us
Contrac or Re uest for Electrical
Date Rough-In Inspection Required?
ConVador Must Schedule All Rou
� Addresr of Inspe � n- S�reet
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Owner Name , ,
p'vne num�e� a� — unawa �
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�ame
s /Y� �l��f�`ic
�ebphon Number '
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Yes
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REC'D .� a� L � 2008
— One Familv Dwell
Contractor Must Schedule All Final
City ship Ci
/�/D ��
Projed Descxipt' �
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� Fee Calculation
New Home or Associated Structurs Existing HomelStructure Remodel or Addition
New Dwelliny Service/Power Supply 0- 400 ampero � 335 New Service/Power Supply 0- 400 ampere � S35
- New L�rsllhig Sarvlce/Pcvrer Supply 401 - 80� ampere (ci� S60 New Seroice/Power SuppN 401 - 800 ampere � S60
New Owslliny FeederslCircuits New Feeders/Circuits - Up to 15 FeedeNCircuits
U� to 30 FesderNCircuks - 100 Feedsra/Cl►cult� 30 E�Ch or 16 to 30 100
New Home - More than 30 Feeders/Circuits (in addkion to New FeederslCircuita - Morei Than 30 Fesders/Cfrcuits
To 200 A
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampero � S35
New Fssders/Circuits � }��o cr-u`� �
to 200 A
Detached Garage or Other Associated Structure
New Service/Power Suppy 0- 400 ampere � S35
:s;:::� �eeder .�C�rc�,!Ei, (, ) � S6 Esch
Reconneded FeedersiCircuits ( ) � S2 Each
TOtel (ths fse calculatad above or S35 multiplied TOtal (the fee calculated above or i35 mulNplied
by tha number ot required inspection trips, by the number oi requirod inspecNon trips, �-��.'`
whichever is reater) � � Y ��
whichever ia yreater) 9
R�qwsb for El�ctrlcal Insp�etlon (REI) wkh a fN o! i250 or bss �xpin 12 months from th� flling dat�. Th� caitraetor must haw fM warlc compNt�d wHMn
th� 12 monN p�Aod or submk anotMr REI fhat Inelud�s th� Inspsctlon he tor th� uncomplat�! work. InspecUon t�u do not carty owr irom on� REI to
anoth�r.
A s�rvle� charg� of 5.10 wlll b� add�d for all dishonorod ch�cb.
1 hereby certiy that I inspected ths NecUical Mstaliation herein on the dates stated: For Dsparbmnt Us� Ony
Rough - In Inspedion(s) Date
Final Inspedion
+��� (` ,it
This mabri�l can b� mad�
TDD (651) 287�419t.
REI 02 (8/07)
Date
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ch as larg� pr
or on a taps. To roqu�t,
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