P - 75712Minnesota Depa of Labor and Industry
443 Lafayette Ro„ North
St. Paul, MN 5 5-4342
Phone: (651) 5064
T1Y/MRS: 1) 297-4198
www.eled ' .state.mn.us
Contractor Re uest for Electrical
��e� � Rough-In Inspecdon Required?
�� Contractor Must Schedule All Rou
Address of Inspection - Street
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Owner Name
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Owner Telephone NumbeKs) - Indude Area Code(s)
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Contractor Telephone Number
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ContractorAuthorized Signature
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tion — One Famil Dwellin /Associated Structure
Yes Single Inspedion Other Than Rough-In: Ready Now
:ctions Contractor Must Schedule All Final Insoections n Will Schedule
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Project Description
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Contractor Mailing Address
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Contractor E-mail Address Electrical Utility
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Contractor License Number JoblProject Contact Person
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� Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0- 400 ampere @$35
New Dwelling Service/Power Supply 401 - 800 ampere @$60
IVew Dwelling Feeders/Circuits �
New Home -
to 30 Feeders/Circui� - $100
s/Circuits (in addition to
s Ua To 200 A C� $6 Each
Detached Garage or Other Assoclated Structure
New Service/Power Supply
Newr Feeders/Cirp!its
Other
0 - 400 ampere @ $35
( ) n $6 Ea�
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0- 400 ampere @$35
New Service/Power Supply 401 - 800 ampere �$60
New Feeders/Circuits — Up to 15 Feaders/Circuits ��
( �) Feeders/Circuits @$6 Each or 16 to 3� �$100
Newr Feeders/Circuifs - More Than 30 Feeders/Circuits
Detached Garage or Other Associated Structure
New Service/Power Suppiy 0- 400 ampere @$35
Pae�� Fee�±err�Circtiits � �.s�„ — ( � ) r^�,,J :5 �sGh
Reconneded Feeders/Circuits ( ) @ $2 Each
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Tot'dl (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)
Requests for Electrical Inspectlon (REI) with a fee of 5250 or less expire 12 months from the filing date. The contractor must have the work completed within
the 12 month pallod or aubmtt enother REI that includes the ins�on fee for the uncompleted wark. Inspectlon fees do not carry over from one REI to
another.
A service charge oi S30 will f� added for all dishonored checks.
I hereby certiry that I inspeded the electrical fnstallation herein on the dates stated: For Departrnent Use Only
Rough - In Inspection(s) Date
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This material can bb�fiiade available in different forms, such as large print, Brellte or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297�198. �
REI 02 (6/07}