P - 76893Minnesofa Depa t of Labor and Industry �O� � O/��,�%
443 Lafayette R North � �
St. Paui, MN 55-4342 ���p AU G 2 7 2007
Phone: (65 84-5064
TTY/MRS� 51) 297-4198
www.e{e city.state.mn.us
Homeowner Re uest for Electrical Ins ection
Date Rough-In Inspection Required? ❑ Yes Inspection Other Than Rough-In: ❑ Ready Now.
�j' ��" �� Homeowner Must Schedule All Rou h-In Ins ections Homeowner Must Schedule AII Final Ins ections �ill Schedule
Address of Inspection — Street City/Township County
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Owner Name Project Description
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Owner Telephone Number(s) — Include Area C e(s) / i l,, �` ,,f C,� �, �� �� C ��(�f
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Owner Maifing Address — Street ' � S�, C�Y State Zip Code
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Owner E-mail Address Electrical Uti(ity
By signing this document, I certify that I am the owner as defined by Minn. Stat § 326.01 and will legalfy perform the electrical work
New Home or Associated Structure
New Home Service/Power Supply 0— 400 ampere @$35
New Home ServicelPower Suppy 401 — 800 ampere @$60
New Home Feeders/Circuits
Up to 30 FeederslCircuits - $
New Home — More than 30 Feeders/Circuds (m adddion to
above) ( ) Feeders/Circuits Up To 200 A(a� $6 Each
Other (Specify)
Fee Calculation
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
IVew Senric�/Povver Suppty 4fYf-� 800 ampere ��64
New Feeders/Circuits — Up to 15 Feeders/Circuits
100 FeederslCircuits $6 E�ch or 16 to 30 $100
New Feeders/Circuits — More Than 30 FeederslCircuits
Feeders/Circuits U to 200 A $6 Each
Reconne tl Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New ServicelPower Suppfy 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each New Feeders/Circuits ( ) @ $6 Each
Other (Specify) Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) Other (Specify)
Total (the fee calculated above or $35 multiplied Total (fhe 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 Inspection (REI) with a fee of $250 or less ezpire 12 months from the filing date. The owner must have the work completed within the
12 month period or submit another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REf to another.
A service char e of $30 will be added for all dishonored checks.
I hereby certify fhat I inspected the electrical installation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) Date
This material can be made available in
TDD (651) 297-4198.
REI 01 (6/D7)
Date
/l �`�-G7
forms, such as large print,
or on a tape. To request, cau i-soo-34z-sa
or