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Minnesota Dep ent of Labor and Industry pC'(�fD A� n� c) 2007
443 Lafayette ad North I�CI. !YU d
St. Paul, MN 5155-4342
Phone: (6 284-5064
TTY/MR 651) 297-4198
www.ele city.state.mn.us
Co ractor Re uest for Electrical Ins ection - One Famil Dwellin /Associated Structure
Date Rough-In Inspection Requiredl �.Yes Single Inspection Other Than Rough-In: Ready Now
/� ;� 2- V Contractor Must Schedule All Rou h-In Ins ections Contractor Must Schedule All Final Ins ections Will Schedule
Address of Inspection - Street CitylTownship � County
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Owner Name , Proje Descripti �2� . � �.. �
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Owner elephone Number(s) - nclude Area Code(s)
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�ontrac�or Name � Cnntractnr Mailing Addres
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Contractor Telephone Number Contractor E-mail Add ess Electrical Utility -
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Cpntractor+Au oriza�i S�nature Contr��tetLicense Num,tzer ,;ob,'P;o � t Co,,iast Pecson i
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Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0- 400 a re Q$35 New Service/Power Supply/�(S� 0- 400 ampere @$35 s��
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New Dwelling 5arvice/Power Supply 401 - 800 ampere (� $60 New ServicelPower Supply 401 - 800 ampere Q$60
New Owelling Feeders/Circwts New Feeders/Circuits - Up to 15 Feeders/Circuits
Up to 30 Feeders/Circuits - 5100 Feeders/Circuits $6 Each or 16 to 30 $100 �_��
New Home - More than 30 Feeders/Circuits (in addition to New Feeders/Circuits - More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each Feeders/Circuits Up to 200 A $6 Each
Other (Specify) Reconnected Feeders/Circuits —
Feeders/Circuits $2 Each ,s2
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/POwer Supply 0- 400 ampere @$35 New Service/Power Supply 0- 400 am ere
p @ $35
New Feeders/Circuits ( )@$6 Each New Feeders/Circuits
( ) @ $6 Each
Other (Specify)
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) Other (Specify)
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TOt81 (the fee calculated above or $35 multiplied TOt81 (the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection tri s
whichever is greater) whichever is greater) p' Q��
!
Requests for Electrical Inspection (REI) wlth e fee of i2S0 or less expire 12 months from the filing date. The contractor must have the work completed withln
thQ 1Z mOnth porlod or submft another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from orie REI to
another.
A servlce charge of 530 will be added for all dlshonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: –
Rough – In Ins io (S For Department Use Only
; Date
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Fi�al Ins ectio Date
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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-DLI) Voice or
TDO (651) 297-4798.
REI 02 (6/07)