P - 76816Minnesota De ment of Labor and Industry
443 Lafayett oad North
St.� Paul, M 55155-4342
Phone: ( ) 284-5064
TTY/MR (651)297-4198
www.el ricity.state.mn.us
Homeowner
Date Rough-In inspection Required?
� Homeowner Must Schedule All Rc
Address of Inspection ,— $treet_ . , _
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Owner Telephone
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Owner Mailing Ad
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uest for Electrical Ins ection
Yes inspection OtherThan Rough-fn: Ready Now
Ins ections Homeowner Must Schedule All Final Ins ctions ❑ V11ill Schedule
City/Township Coun
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Projed Description t
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�er(s) — Include Area Code(s)
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Electrical Utility
By signing this do�a�ment, I certify that I am the ownerfas �efine� Minn. StaL § 326.01 and will legally perform the electrical work
Fee Ca{culation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Home Service�'Power Supply 401 — S00 empere @ S6a New Savvice/Povver Suppiy 40'! —�00 ampere @$64.
New Home Feeders/Circuits New Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addition to New Feeders/Circuits — 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/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each New FeederslCircuits ( ) @ $6 Each
Other (Specify)
Reconneded Feeders/Circuits ( ) @ $2 Each
Other (Specify) Other (Specify) a �p�� .�L%,
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Totel (the fee calculated above or $35 multiplied TOt81 (the fee calculated above or $35 multiplied _—�—
by the number of required inspection trips, , by the number of required inspection trips, �( j ;��
whichever is greater) whichever is greater) �"
Requests for Electrical Inspection (REI) with a fee of 5250 or less ezpire 12 months from the filing date. The owner must have the work completed within the
12 morrth period or submk another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REI to another.
A service cha e of S30 wlll be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dat� stated: For Department Use Only
Rough — In Inspection(s) R/� '/� `P �Date
�/y �— ` J .
G:.,�i �„�.,o,�r��� Date
This material can e ava� e in different forms, sucMf as large print,
TDD (651) 297-4198.
REI 01 (6/07)
or on a
To request, call 1-800-342-5354
Voice or