P - 75387Minriesota Departnpe of Labo� and Industry
d43 Lafayette Roa�j' orth•
St. Paul, MN 55 342
Phone: (651) 2 5064
TTY/MRS: (6 297-4198
. www.electri .state.mn.us
Contr tor Re uest for Electrical
� 1e Rough-In Inspection Required?
I� ��`�� Contractor Must Schedule All Rou
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tion — One Famil Dwellin /Associated Structure
Yes Single Inspedion Other Than Rough-In: Ready Now
rctions Contractor Must Schedule All Final Ins ec�ions Will Schedule
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� Fee Calculation
New Home or Associa4ed Structure Existing HomelStructure Remodel or Additlon
New Dwelling ServicelPower Supply 0- 400 ampere (� $35 New Service/Power Supply 0- 400 ampere @�35
r---'e.v--^'sseUn;-S��?c�^�e� ��!��� �L-__�.4�_?m�ere (� S60 Naw Service/Power Suppl�r _ 401 - 8Q0 ampere aLD $60
New Dwelling Faeders/Circuits Nerv Feeders/Circuits - Up to 15 Feedars/Circuits
1,0� to 30 Feeders/Circufts - 100
New Home - More than 30 Feedera/Circuiis (In eddftfon to
abova Feeders/Circuits U To 200 A 6 Each
Other (Soecifvl
- More Than 30 Faede
rs/Circuits Un to 200 A
r G
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Feeders/Circ�its $2 Each
Detached Garage or Other Associated Structure � Detached Garage or Other Assoclated Structure
New Seroice/Power Supply 0- 400 ampere (�,.D b35 New Service/Power Supply 0- 400 ampere (p� �35
New FeederslCi�cuits ( )(g'� $6 Each New FeederslCircuits ( )� a6 EaGt
Other (Speciy)
Reconnected FeederslCircuits ( ) (Q1� s2 Each
Other (Specify) Other (Specif�rj ��� �,�
Total (the (ee calculated above or s35 multiplied TOtal (the fee plculated abova or �35 multiplied
by the number of required inspection trips, by the number of required 'mspectlon Vips, �, j r�
whichever is greater) whichever is greater)
Requesta (or Elactrlcal In�pectlon (REI) wtth a tee of 5280 or lesa explre 12 months Prom the flling dafe. Tha corMractor must have the work cnmpleted withits
the 12 month perlod or submit another REI th�t Includes tha I�spacUon fee for the uncompleted wark. Inspecdon faes do not carry ovar irom ons REI W
anothar.
�/�o Gv�� �� A sarvtea charge of S30 wlll be added tor all dlahonored ch�ks.
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I hereby certity that I inspected the electrical installation herein on ttre dat� staled: For Depertment U Only
Rough - In Inspection(s) Date � � � � m. (`��C�'Y �
Fi al Inspedion /, ,_ pate � REC'D S E P 2 2 2008 ,
ihl� materlrl csn ba
rao �sa�y 2s�.��ee.
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