P - 75718Minnesota Depa 4�t of Labor and Industry
443 Latayette Ro �`�lorth
St. Paul, MN 55 5-4342
Phone: (651) 5064
TTY/MRS: ( ) 297-4198
wMrw.electri .state.mn.us
Contractor Re uest for Electrical Ins
Da���Rough-In Inspe�tion Required?
0� Contractor Must Schedule All Rou h-In
Address of Inspedi n— et
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�tion — One Famil Dwellin
Yes Single Inspedion Other Than
sctiens Contractor Must Schedule All
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iated Structur�
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E-mail Address
� Fee Calculation
New Home or Assoclated Structure Existing Home/Structure R�model or AddiUon
N�r Dwelling Service/Po�er Supply 0— 400 ampere @► S35 New ServicelPower Supply 0— 400 ampere (a13 S35 �� �
New Dwe�ing SenricetPoHrer S�rppty 401 — 800 ampere � S60 New Service/Power Supply 401— 800 am�re � 360 ���
New Mome —
New Feeders/Circuits — Up to 15 F�derslCircuits
;-$100 � Feeders/Circuits S6 Ea� or 18 to 30 100 �
to New Feedere/Circuits — More Than 30 FeederslCircuila
. . I . � r....de.otrt.....tb � 1.. ►.. 9ftf1 A l.i1 tR �nrh
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere (Q� E35 New Servica/Power Supply 0— 4� ampere � S35
New Feedets/Circuits ( )(� 56 Each New FeederslCircuits ( )@ 36 Eect►
Other (Specify) Reconneded Feeders/Circuits ( )� S2 Each
Other (Speay) Other (Specily) ��
e
Total (the fee calculated above or S35 multiplied TOtel (the tee calculated above or S35 multiplied �
by the number of required inspection trips, by the number of required inspectlon Vips, ?
whichever is greater) whichever is greater)
Requesta for ElecMwl Inspeetion (REI) with a fee of t250 or less expire 12 mon�s from the Bting date, The eontractor murt have the wark eompteted �r(th�e
tha 12 month perlod or submk arrotAer REI ehat I�ludee the Inspecdon fee tor the uncompiete� work. Inapecdon feea do not carry over fiom one REI to
an�hBr.
A servlee charge of i30 wtll ba adiled for all alehonored ehaeks.
1 hereby cerGy that I inspected the alectrical instaAadon h�refn on the dates steted: For Depertr�nt Uae Only
Rough — In Inspection(s) Date
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Thls mabrial ean bs ma s avallsble in dlifsrent tornis, such aa large print, Brallle or on a tape. To requast, eall 1-8��42 8364 (DIAL DU) Voice or
TDD (661) 287�19H.
RE102 (8/07)