P - 76834Minnesota Departm of Labor and Industry
443 Lafayette Roa orth
St. Paul, MN 551 342
Phone: (651) 2 5064
TTY/MRS: (6 297-4198
www.electrici tate.mn.us
Contra or Re uest for Electrical Ins
Date Rough-In Inspection Required? .
i�' �� �� Contractor Must Schedule AIl Rou h-In I
Address of Inspection — Street
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Owner Name
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Owner Te�ephone Number(s) — Include Area Code(s}
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RESIDENTIAL ELECTRICAL PERMIT BY CONTRACTOR
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RECEIVED: Mr► ��n�► ,T� t1f17
on — One Famii Dweliin lAssociated Structure
;S Single Inspection Other Than Rough-In: � Ready Now
ions Contractor Must Schedule All Final Ins dions ,�-Will Schedule
CitylTownship County
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Projed Descriptio
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Contractor Name ContreCto� nnamng Hoaress
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Contractor T lephone Number Contrador E-mail Address
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�' tractor A orized Signature Contractor License Number
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Electrical Utility
Contact Person
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Fee Calculation
N w Home or Associated Structure Existing Home/Structure Remodel or Addition
e
New Dwelfing Service/Power Supply 0— 40U ampere @$35 '
New Dwelling Service/Power Supply 401 — 800 ampere @$60
New Dwel{ing Feeders/Cirwits
Up to 30 FeederslCircuits -
New Home — More than 30 Feeders/Circuds (�n add�tion to
�ti,,..o� i � Feeders/Circuits U� To 200 A@$6 Ea�
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Other (Specify)
Other
( ) @ $6 Each
New Service/Power Supply
New Service/Power Supply
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New Feeders/GrcuRS —
0 — 400 ampere @ $35
401 — 800 ampere @ �60
15 Feeders/Circu'its
>$6Eachor16to30@$100
Than 30 Feeders/Circuds
iits Up to 200 A@$6 Each
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KBCOfIflBC�eu rCCUC��vu�.��w l�,�j QO
( ) Feeders/Circuits (r� $2 Each 7�"
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Reconnested Feeders/Circuits
( ) @ $6 Each
( ) � $2 Each
TOtal the fee calculated above or $35 multiplied
Total (the fee calculated above or $35 multiplied (
by the number of required inspection trips, by the number of required inspection trips, 9, 00
whichever is greater) whichever is greater) �
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Requests for Electrical Inspection (REI) wiffi a fee of $250 or Iess expfre 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 wrty over from one REI to
another.
A service charge of S3� will be added for all dishonored checks.
I hereby certi(y that I inspeded the electrical installation herein on the dates stated: For Department Use Only
Rough — In In�,peztiqn(s) Date
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This material can di
TDD (651) 297-4198.
REI 02 (6/07)
Date
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available in different forms, such as large pnnt, Bradle or on a
ro request,
Voice or