P - 76844Minnesota Department of Labor and Industry
443 Lafayette oad North
St. Paul, MN 5155-4342
Phone: (651- 284-5064
TTY/MRS: '651) 297-4188
www.electri 'ty.stafe.mn.us
Contr 'tor Re uest for Electrical Ins
Date Rough-In lnspection Required?
�/� �� �� Contractor Must Schedule All Rou h-In
Address of Inspection — Street
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Owner Name „
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Owner Tel hone Number(s) — Include Area Code(s)
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Contrector Name
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Contractor Telephone Number
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�Contractor Author¢ed Siqnature
RESIDENTIAL ELECTRICAL PERMIT BY CONTRA.CTOR
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PERMIT # � � . . A i
RECEIVED: +
tion - One Famil Dwellin lAssociated St cture
Yes Single Inspection Other Than Rough-In: Ready Now
�ctions Contractor Must Scheduls All Final Insnedions �] Will Schedule
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Contractor Maifing Address " �
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Contractor E-mail dd s� C��
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Contractor License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Suppfy 0— 400 arr�pe� @$35
New Dwelling ServicelPower Supply 401 — 800 ampere @$60
New Dwel(ina Feeders/Circuits
Home — More than 30
(Specify)
to 30 Feeders/Circuits -
s/Circuits (in addition to
s Uo To 200 A(a� $6 Eai
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
0 — 400 ampere � $35
( ) @ $6 Each
Electrical Utifi y
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Existing Home/Structure Remodel or Addition
New Service/Power Suppfy 0— 40D ampere @$35
New Service/Power Suppiy 401 — 8D0 ampere @$60
New Feeders/Ci►cuits — Up to 15 Feeders/Circuits
( ) Feeders/Circuits @$6 Each or 16 to 30 @$100
New Feeders/Circuits — M�re Than 30 Feeders/Circuits
( ) Feeders/Circuits Up to 200 A@$6 Each
Reconnected Feeders/Circuits
Detached Garage or Other Associated Structure
New ServicelPower Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Reconnested FeederslCircuits ( ) � $2 Each
Other (Specify) Other (Spec�ty)
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Total (the fee calculated above or $35 muftiplied TOtal (t e fee calculated above or $35 multiptied
by the number of required inspection trips, by the number of required inspection trips, �
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of i250 or leu expire 12 months from the filing date. The corrtractor must have the work completed within
the 12 month period or submk anoiher REI that includes the inspection fee for the uncompleted work. Inspectfon fees do not carty over from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
I hereby certify that I inspeded ttie electrical instaltation he2in on the dates stated: For Department Use Only
Rough — In Inspection(s) Date
Final Inspection
This material can bi
TDD (651) 297-4198.
REI 02 (6/07)
Date
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forms, such as large print, Braille or on a tape. To request, call 1
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