P - 76950Minnesota Dep 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
Contractor Re uest for Electrical In
at Rough-In Inspection Required?
Contractor Must Schedule All Rou h-I
res of Inspection —
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REC'D S E P 13 2007
s ection — One Famil Dwellin lAssociated Structure
❑ Yes Singie inspection Other Than Rough-In: y� Ready Now
n Ins ections Contractor Must Schedule All Final Ins ections'� Will Schedule
City/To�wr ship _p , _ County
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lephone Number(s) — Include Area Code(s)
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Project Description �
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�actor Name -� � Contractor Mailing ress
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ractor Telep ne Number Contractor E-mail Address Electrical Utility
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�ac o� Aut riz Signature Contractor L' ense Number� Job/Project,Cqrt'�a t P so
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Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwellirtg Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60
New Dwelling Feeders/Circuits
Up to 30 FeederslCircuits - $100
New Home — More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A@$6 Each
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Other (Specify)
Other
( ) @ $6 Each
0
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/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 Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied • 1/ --T
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 $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 installatio� herein on the dates :
Rough — In Inspection(s) Date
nspection
This material can be made
TDD (651) 297-4198.
REI 02 (6/07)
/a ^1��.�
For Department use vnry
such as large print, Braille or on a tape. To request,
(DIAL-DLq Voice or