P - 75647Minnesota Depa - nt of Labor and Industry
443 Lafayette R d North ' �
St. Peul, MN 155-4342
Phone: (651 84-5064
TTY/MRS: 51) 297-4198
www.ele ity.state.mn.us
Cont actor Re uest for Electrical I
Dat Rough-In Inspection Required?
� OV Contractor Must Schedule Atl Rou I
Ad ress f Inspe ion — Street
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TeleRhone Number
�tion — One Famil Dwellin /Associate tructure
Yes Singte Inspection Other Than Rough-In: Ready Now
ictions Contractor Must Schedule All Final Ins ctions ❑ Will Schedule
City/� owy�ship , County ,,
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Area Code(s)
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^ Contractor Mailing Address
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Contractor E-mail Address Electrical Utility
Cont�actor License Number JoblProject Contac;
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'" Fee Calculation .
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0— 400 ampere @$35 New ServicelPower Supply 0— 400 ampere @$35
New Dweliing Service/Power Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Dweliing Feeders/Circuits New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 Feede�slCircuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addition to New ended Feeders/Circufts — More Than 30 Feeders/Circuits
above) Feeders/Circuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) Reconnected Feeders/Cirr.uas
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
_ ( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New Senrice/Power Supply 0— 400 ampere @$35
New/Extended FeederslCircuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied "z'� �"
by the num6er of required inspeetion trips, by the number of required inspection trips,
whichever is greater) whichever is greater)
Requests for Electrical inspection (REI) with a fee of E250 or less expi►e 12 months from the flling date. The cont�actor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inapection fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dfshonored checks.
t hereby certify that I inspected the electricai installation herein on the dates stated: F Dep�m� Use Oniy
Rough — In Inspection(s) Date , r'id� `
nspection
Thls materldT can be made
TDD (851 � 287-4198.
REI 02 (6/07)
� Date
C�.�—� � `
forms, such as lan
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I�D J U L 0�2 �00�
or on a tape. To request, calt
or