P - 75573Minn�sota Depa ent of Labor a�d Industry
, 443 Lafayette R d North
St. Paul, MN 5 55-4342
Phone: (651) -5064
TTY/MRS: ( 1) 297-4198
www.electri .state.mn.us
Contractor Re uest for Electrical In
�� ��Rough-In Inspection Required?
Contractor Must Schedule All Rou h-I
A d���lqspectior�� eet �� ��
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ep�e ber�) — In Area S�qde(s)
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Name Contr� Mail`ng
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Contractor E-mail �
:tion — One Famil Dwellin /Associat Structure
Yes Single Inspection Other Than Rough-In: eady Now
�ctions Contractor Must �chedule All Final Ins ctions ❑ Will Schedule
City ownship County
Project Description
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itno q'ignature Contractor 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
Up to 30 FeederslCircuits - $
New Home — More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A $6 Each
Other (Specifvl
Detached Garage or Other Associated Structure
New Service/Power Supply 0-400 ampere @$35
New FeederslCircuits ( ) @ $6 Each
Other (Soecifv)
Electrical Utility
Existing Home/Structure Remodel or Addition
New Service/Power Supply
New Service/Power Supply
Feeders/Circuits
0 — 400 ampere @ $35
401 — 800 ampere @ $60
Is — Up to 15 Feeders/Circuits
$6 Each or 16 to 30 @$100
— More Than 3D Feeders/Circur
ts Up to 200 A(a� $6 Each
( ) 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 Feede�s/Circuits ( ) @ $2 Each
r ,
/�
Total (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied -�'�
by the num6er of required inspection trips, by the number of required inspection trips, �
whichever is greater) whichever is greater) �
Requests for Electrical I�spectlon (REI) with a fee of 5250 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 inspeetion fee for the uneompleted work. Inspection fees do not carry over from one REI to
another.
y�,� A service charge of $30 wi e added for all dishonored checks.
I hereby ceAify that I inspected the electrical installation herein on the dat stated: For Department Use Only
Rough — In Inspection(s) te f'� /�� � � ��� � /
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F' I Inspection Date ��p A U G 2� 9 2008
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Thls matehal ca e made avatlable tn dlfferent form , such as large print, Brallle or on a tape. To request, call 7-800-342-b364 (DIAL-DLI) Volce or
TDD (857) 297�4198.
REI 02 (6/07)