P - 76674Minnesota Department of Labor and Industry
443 Lafayette Ro d North
St. Paul, MN 55 5-4342
Phone: (651) -5064
TTY/MRS: (6 297-4198
www.electrici state.mn.us
Contra or Re uest for Electrical Ins
I����w Rough-In Inspection Required?
(7�) Contractor Must Schedule All Rouah-In I
Owner N e "
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Owner Tel�hone Numaer(s)�.,Include Area Code(s)
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or Name
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or Telephone Number
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or Au r d Signatu/rP.//�
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REC'D O C T 2 9 2007
tion — One Famil Dwellin /Associated tructure "
Yes Single Inspection Other Than Rough-In: eady Now
�ctions Contractor Must Schedule All Final Ins ections ❑ Will Schedule
City/Township , , County_
ProjectD
Vv�
Contractor Mailing Address
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Cont tcar or E-mail Address
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
� � nse Number
1 �
Fee Calculation
New Dwetling Service/Power Supply 401 — 800 ampere @$60
above
Up to 30 Feeders/Circuits - $100
than 30 Feeders/Circuits (in addition to
Feeders/Circuits Up To 200 A@$6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Other (Specify)
( ) @ $6 Each
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Electrical Utility
Job/Proj
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
( ) Feeders/Circuits @$6 Each or 16 to 30 @$100
New/Extended Feeders/Circuits — More Than 30 Feeders/Circui
( ) Feeders/Circuits Up to 200 A@$6 Each
Reconnected Feeders/Circuits
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (SpeciNl
Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied `c�
by the num6er 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 $250 or less expire 12 months from the filing date. The contractor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) Date
Final Inspection
i nis materiai can a�
TDD (651) 297-4198.
REI 02 (6/07)
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�ble in different forms, such as large print, Braille or on a
request, call 1-800-342-5354 (DIAL-DLI) Voice or