P - 75383Minnesota Department of Labo�'and Industry
443 Lafayette Road Nort11 ,
St. Paul, MN 55155-434 <
Phone: (651) 284-5064<"
TTY/MRS: (651) 297 98
www. electriaty. state. . . us
Contractor e uest for Electrical In
Date Rough-In Inspection Required?
�t f��d `�''' Contractor Must Schedule All Rou h-I
Address of Inspe ion - t t
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ir Name
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ir Telephone Num er
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��thorized Si re
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tion — One Famil Dwellin /Associated Structure
yeS Single Inspedion Other Than Rough-I�: Ready Now
:ctions Contractor Must Schedule All Final Ins edions wll Schedule
CitylT�ship�� Counry ��o �
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Projed Description
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Contractor M 'ling Address
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Contractor E-mail Address Etectrlcal dlity
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Contra or License Nu Job noject Contact
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Fee Calculation
New Home or Assoclated Structure
New Dwelling Service/Power Supply 0— 400 ampere (� $35
Mew Dwelling Service/Power Supply 401 — 800 ampere (d� S60
New Dwelling Feeders/Circuits
Up to 30 Feedera/Circuffa - 31 �
New Home — More than 30 FeederslCirc�its (in addition to
abovel f • 1 FeederslCi�cuits Uo To 200 A Cdt SB Each
6etached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere (@ 535
New Feeders/Circuits ( ) (Q'� $6 Esch
Other (Speclly)
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0
Existtng Home/Structure Remodel or Addition
New Service/Power Supply 0- 400 ampere (a� 335
Nevr Service/Power Supply 401 — 800 ampare �$60
New Feeders/Circuib — Up to 15 Feadera/Cfrcuits
Feeders/Circuits 38 Each or 18 to 30 100
N�r FeederslCircuits — More Than 30 FeederslCircufts
I 1 Feeders/Circuits Uo to 200 A(a� 36 Each
Detached Garage or Other Assoclated Structure
New Service/Power Supply 0- 400 ampere (� S35
New FeedersJCircuits ( ) (� S6 Each
Reconneded Feeders/Circuits ( ) (Q13 S2 Each
�h@f (SpBCliy) �a y � a _ . �-'�
�ray,;-
TOtel (the fee calculated above or s35 multiplied TOtel (the fee plculated abova or a35 muftfpl�d S
by the number of required inspection trips, by the number oi required inspedion trips, ��
whichever is greater) whichever is greater)
Requests tor Eleetrleal Inspectlon (RE1) wlth a fee of s4b0 or less explre 12 months from tha filing date. Ths conQractor muat have fhe work completed wHhin J���
ths 12 month pa�lod or aubmh another REI th�t I�ludes the IospecUon fee trnr the uncompleted wwk. lnepectlon taes do not prry ovar irom ons REI to
anather.
A ssnics cha�e of S30 wlll ba added tor ail dlahonored chacks.
I hereby certily that I fnspeded Ihe eleclrical installalion herein on the dat�s steled: For Department U�nly
Rough - In Inspedion(s) Date ri /`6'�1� ,� t� l-� '�
Q(l1lJ
Final Inspection Date �� N p V fl 7 200�
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Thls mateNN can be mad� �vailabla In dlHoront Tom�s, euch aa la►ge prin rattle or on e taps. To roquest, eall 1-8�-3142-6364 (DIAL-DU� Volee or
TDD (851) 297-�19B.
REI 02 (8/07)