P - 75541Minnesota
443 LafayE
St Pau1,1�
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Add�ss o
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Ovmer Na
)e�Ftrnent of Labor and Industry'
��Road North
J 55155-4342
1) 284-5Q64
(651)297-4198
�it�+.�.mn.us
�ctor Re uest for Electrical
_ Rough-In inspection Required7
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C�ntrac�or Name
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nber(s) — Include Area Code(s)
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F`��SSfD�NTIaL �LECTRICAL PERMIT BY CONTRACTOR
PERMIT #
R�CEN�D: �
— Or�� �a�mi! L?w����i�n /A�sc�c�ai+ed �ttvciure
5ingle In�pecs6ian Other'I'han Rough-In: Ready Now
Contractor Must Schedule All Final Inspections ❑ Will Schedule
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jeet Des ' tion �
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Fee Calculation
New Home or Asscciated Structure Existing Home/Structure Remodel or Addition
New Dweliing Service/Power Supply 0— 400 ampere �$35 New Sanrice/Power Supply 0— 400 ampere @$35
New Dwellirtg Service/Power Supply 401 — 6D0 ampere �$6Q New Service/Power Supply 401— 800 ampere �$60
New DwelHng Fee�e�l�ircaiEs _ N�F�ci�t�/Circui�s — Up to 15 Feeders/Circuits
Up to 30 FeederslCiraiits - $100
— More than 30 Feeders/Circwits (in addi�on to
) Feeders/Circuits U� To 200 A C�D $6 Each
Detached Garage or Other Associated Structure
New ServicelPower Supply 0— 400 ampere �$35
New FeederslCircuits ( ) @ $6 Each
— More
Reconneded
$10�
:UItS
Each
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( ) FeedersJCirc�its $2 Each I
Detached Garage or Other Associated Structure
New Service/Power Suppiy 0— 40D ampere @$35
New FeedersJCircuits ( ) � $6 Each
Reconneded Feeders/Circuits ( ) � $2 Each
Total (the fee calculated above o� $35 multipCed TOtal (the fee calailated above or $35 mu(tiplied �n,�
by the number of required inspedton trips, . by the number of required inspedion trips, �� v
whichever fs greater) whichever is greater)
Requests for Elech�ical Inspection (REI) with a iee of 5250 or tess e�cpire 12 morrths from the flNng date. The contractor must have the work compteted within
the 12 morrth �riod or submk another REI that Inrdudes the Inspeetion fee for the uneompleted work. inspecdon fees do not cariy over from one REI to
another.
A service charge of E30 will be added for all dishonored checks.
I F�reby certlty that I ed the electrical instatlatlon herein on the dat� stated: For Departrnent Use Only
Rou — n I sp 'on(s Date
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Final Inspecti� , p e ��„, t U� � 2008
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This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DU) Voice or
TDD (6b1j 297-4198.
RE102 (6/07)
RECD J U L 10 2008