P - 75559Minnesota Depart,: ent of Labor and Industry
443 Lafayette R" d North
Si. Paul, MN 5 55-4342
phone: (651),- 4-5064
TTY/MRS: 1) 297-4198
www.elect y.state. .us
Con r� uest for Electrical Ins
Date , Rough-In Inspection Required? [
�.�� Contractor Must Schedule All Rough-in In
dress of Inspection - Street �
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Qwner Name f n �/� ,�� �+
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Owner Telephone umber(s) -- Include Are od s)
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Contractor Nam , ,,�-. ��jj tor
- - -�.`�. _-_��4,T91`�r�.� $� 0
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Contra�tor Telephone Nur�S�'q� @4/�
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C:ontractor
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;tion - One Famil
Yes Single Inspection
ections Contractor Must ;
Mailing Address
E-mail Address
illlllllllll �
D Ilingl
�ther Than Rouc
chedule AI( Final
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II�III�IIIIIIIIII
�iated tructure
Ready Pdow
ions � WiII Schedu
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�escription ' ' �
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� Eiectrical Utility ^ !
�
� Gontract Lic nse Number ��� lob/Project Contact Person
� - ' - - --�� � ��-�'�'�-____ __. �------- -- -
----_.._.. .�J_ .....__..__--...----•-----�---- -_..__ ...
Fee Calculation ��� � � --
___. -- ---- - ---_ _.,— ------ �. - ._
--------- ,_�
,-
New Home or Associated Structure
New pwelimg Service/Power 5upply 0- 4qp ampere @$35
New Dweliing Serv�ce/Power Supply a01 - 6G0 ampere @$60
Ncw Dwelling FeederslC�rcuits� � l
U�to 30 FeederslC�rcurts - $10C
New Home - More than 30 Feeders/Circuits (in addition te
,ai�:�ve; , -_LFeeders/Circuits U To Z00 A(a� $6 Each _
lther (Spe.r,ify)
Detached Garage or Other Associated Structure
__ _------ -- .__---- ._. �.
r•:ew Service/Power Suppiy 0- 40C1 ampere ra $35
N�s�N Feeders/Circuits ( � ,on� $E Each
�.---_ --. —. _.._..__
- -- -•-._�_ .._.-__.
7ther (Specify)
---�._.�- -------- -._. . .__ _-- - --- . . —
Ouier (Specify)
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0- 400 ampere @$35
- ---------------_ ____ —____..... .�._.._ _�__ _.
—...__-...__�._
New Serv�ce/F'owe; Supplv 401 •- 800 ampere �t7,, �60
_ ._._ _._.i
New/Extended Feeders/Circuits - Up to 15 Feeders/Circuits
Feeders/Circ�nts �$6 Each or 16 to 30 $100 '
J--- ------ -�-- �° -- + -
New/Extended Feeders/Circuits - More Than 30 FeederslCircuits
i L ) FeederslCircuits U�to 200 A(� $6 Each _ i
i
-- - - -
Reconnected FeederslCircuits I
Feeders/Circuits $2 Each i
._ _ _ --- -._. . _ _. _.. _ __�-__ _-.�L— � - -
Detached Garage or Other Associated Structure
--.._. . _
___.__._ __---- - ----._..�____ _ .
�
New Service/Power Supply 0- a00 ampere @$35
— ----_ __._�_ -- - ---�- -
New/Fxtended Feeders/Grcwts ( ; @ $6 Ea�h �
� '
—__._. .__._.._ __. ___._------...--- ----�- -..._.�__�.��_._..._�
i
Reconr,ected Feeders/Circuits ( 1@$2 Each j
--• --- ___.._._..____..__...--•-__.___. ----- � --
�ther (Specify) _�_.r._.. __-1--
_... --------- — - -- - - -- - - --- ._.._- --- - --- - ;
- ---_._,...—._. __ _ .._- ---�--- �------- . -I__.
Totai (the fee calculated above or $35 multiplied Total ithe fee caiculated above or $35 muitlplied �,)
Uy the number of required inspection trips, by thE number of requ�red �nspection trips, r� ��
whichever �s greater) whichever is greater) �)�� e�
�_ _.___.___��_� __---------_._ .�_._ -- -------•
_.�.�-- -
Requests tor Electrical Inspection (REf) with a fee of 5250 or less expire 12 months from the fi{ing date. The contractor must have the work compieted with
the 12 month period or submit another REI that ineludes the inspection fee for the uncompieted work. I spection fees do not carry over from one REI to
- _____ another.
A service charge of $30 wiil be adaedior att dishono ,__ __ _
_ _� . ..._ --.._.. —_ - --
_. �._....__.__._-----�___�_ . r-------- ---- _ . .._.
! I,ereby certify thaf I inspected the electrical installatinn herein on the dates stated ; For Department Use Only
Rauyh In Inspection(s) Date � ? �p ��
I � �`i � `��
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� �ii�� inspert�nn -- . ---_.. _---..___._.–.---. —_ __._ _ --- Date�---- -1 � S E P 0 4 2008
�-,_�� � h�as lar� rin._i_�_.------...-•--------
This material can be made availabfe in different forms, su g p t, Braille or on a tape. To request, catl 1-800-342-5354 (DIAL-DLI) Vo�c.