P - 75606— Minnesota Depart nt of Labor and Industry ����-�_�
443 Lafayette R , North '� �
St. Paul, MN 55-4342 �
Phone: (651 -5064 �-
TTY/MRS: 1) 297-4198
www.ele ity.state.rhn.us
Contractor Re uest for Electrical
Date Rough-In Inspection Required?
5��'�� Contractor Must Schedule All Ro�
Address of Inspection - Street
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Owner Tele one Number(s) - Include Area
Contractor Name
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Contractor Telephone Number
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�ractor Authoy'r��l Signature
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— One Famil Dwellin /Associated Structure
Single Inspection Other Than Rough-In: � Ready Now
��ntractor Must Schedule All Final Insaections �rchedul
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ject Descriptio
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Co tractor Mailing Address
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Contractor E-mail Address
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Contractor License Number
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F'ee G�Iculate��
New Home or Associated Structure
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��ect Contact Person
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Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0- 400 ampere @$35 I I New Service/Power Supply
New Dwelling Service/Power Supply 401 - 800 ampere @$60
New Home -
Other (Specify)
to 30 Feeders/Circuits - $1
s/Circuits (in addition to
� Uo To 200 A Ca� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other
New Service/Power Supply
New/Extended Feeders/Cir�
0 - 400 ampere @ $35
401 - 800 ampere @ $60
rs - Up to 15 Feeders/Circuits
$6 Each or 16 to 30 @$100
— MnrP Than 30 Feeders/Circuits
A an. $6 Each
Feeders/Circuits
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�Vv
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Struct�are
New Service/Power Supply 0- 400 ampere @�35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Total (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 ElectHcal InspecUon (REI) wlth a fee of $250 or less expire 12 months from the flling date. The contractor must have the work completed n
the 12 month perlod or submit another REI that tncludes the Inspectlon fee for the uncompleted work. Inspectlon fees do not carry over from on I to
another.
A servlce charge of $30 wlll be added�r all dishonored checks. 1%��°
I hereby ' that I inspected the electrical installati n herein on the.dates stated: For Departrnent Use Only
�n Inspection(s) � ����-� Date
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This matertal can bE
TDD (651) 297-4198.
RFi m iFm��
Date
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forms, such as large
or on a tape. To request, call
Voice or