P - 76848Minnesota Depart "ent of Labor and Industry
443 Lafayette d North
St. Paul, MN 155-4342
Phone: (65 84-5064 � �t''� / �
TTY/MRS: 51) 297-4198
www.ele city.state.mn.us
Con actor Re uest for Electrical Ins
Date Rough-In Inspection Required?
`"�"� Contractor Must Schedule All Rou h-In
Address of Inspection — Street
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Owner Name
Owner Telephone Number(s) — Include Area
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tion — One Famil Dwellin /Associated Structure
Yes Single Inspection Other Than Rough-In: � Ready Now
�ctions Contractor Must Schedule All Final Ins ections Will Schedule
City/Township County
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Project Descri ' n
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Contractor Name Contractor Mailing Address
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r License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60 I
New Dwelling Feeders/Circuits �
U to 30 Feeders/Circuits - $100
New Home — More than 30 Feeders/Circuits (in addition to
above Feeders/Circuits U To 200 A $6 Ea�h
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
Other (Specify)
Other (Specify)
0 - 400 ampere @ $35
( ) @ $6 �ach
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Electricai litiiity
Job/Project Contact
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Existing Home/Structure Remodel or Addition
New Service/Power Supply 0�400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60 I
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/Circuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
/ � Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure
New Service/Power Suppty 0— 400 ampe.ra ,an, $35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
TOtal (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, 4 �_�C�
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 nereoy cerary tnat i inspectea �ne eiecmcai �nstauanon nerein on tne aates state
Rough — In Inspection(s) �L-�% 1r �afe�7
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Final Inspection Date
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Department Use Only
fhis maierial can be made available in different forms, such as large print, Brailla or on a tape. To request, cail 1-800-342-5354 (DIAL-DLI) Veice or
-DD (651) 297-4198.
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