P - 75543Minrtesota Depa�tm of Labor and Industry (� �� � e
443 Laf�yette Roa orth �� �
St. Paul, MN 55 2 �� �� �� �
Phone: (651) 5�4
TTY/AARS: ) 29i-4198
wirow.el .state.mn.us
Con ctor Re uest for Electrical Ins ection — One Famil Dwellin /Associated Structure
Date Rough-In Ins�on R�uired? Yes Single Inspedion Other Than Rough-In: [] Ready Now
�6 �� �� Contractor Must Schedule All Rou h-In Ins 'ons Contractor Must Schedule All Final Ins ctions ❑ Will Sche�dule
Ad ress of Inspedion — Street City/Township Courrty
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Ovmer Name rojed De ' 'on
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Owner Tel one Numbe�(s) — Indude Area Code(s)
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Contractor Name Contrador Mailing Address
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Contra Tefephone Number Corrtractor E-mail Address Electrical Utility
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ContraS��rthorized Signature Contractor Lice ' Number Job/Project Contact Person
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'� � '�� Fee Calculation
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New Home or Associated Structure E�cisting Home/Structure Remodel or Addition
New Dwelling Senrice/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Dwelling FeedersiCircuits New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 Feeders/Circuits -$700 F�ders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 F�ders/Circx�its (in addition to New/Extended Feeders/Ctrcutts — More Then 30 Feeders/Ci�cuits
above Feeders/Circuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Spec�fy) Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detsched Garage or Other Associat� Structure De�ched Gafage or Other Associated Structure
Newr Service/Power Supp�y 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each New/Extend� Feeders/Circuits ( � ) � $6 Each
Other (Specify)
Reconneded Feeders/Circuits ( ) � $2 Each
Other (Speay) � Other (Specify)
TOtAI (the fee calcul2ted above or $35 multipli� TOtal (the fee calculated above or $35 multipli�
by the number of required ins�Ctian trips, by the number of �uired ins�on trips, �
whichever is greater) whichever is greaber) �
Requegts for ElecVieal I�pealon (REI) with a tee o? SZSO or tesa exptre 12 moritlfs fra�n the flUne dete. The cor�tractor must have the wark �mpt�ed w�ln
the 12 month period or submit another REI ti�t Includes the ir�pe�tlon fee for the uncomplete� vrw9c. lr�pectla� fees do not carry over irom otre REI to
another.
A eervlee cha�ge of �30 wili be added for aU dishonor� checke.
I hereby certify that 1 inspected the elecdical ir�llation h�ein on the dates stated: For pe� � Use Only
Rough — In Inspedion(s) pate , �
Flnal lns�ion Date RE J U L 0 7 2009
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Thls mateMal can be made avallabte In difterent iorms, such as large print, Brallle or on a ta�. To request, call 1-BOD-342-83b4 (DIAL-DLI) Volce or
TDD (6S1) 297�4198.
RE102 (8/0�