P - 76740Minnesota Depa nt of Labor and Industry
443 Lafayette R d North
St. Paul, MN 55-4342
Phone: (651 84-5064
TTY/MRS: 51) 297-4198
www.ele city.siate.mn.us
Co ctor Re uest for Electrical Ins
Date Rough-In Inspection Required?
�8/�OQS Contractor Must Schedule All Rou h-In
Address of Ins ection - Street
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Owner Name
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Owner Telep one Number(s) -
(s)
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/To nship County
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Project Descri tion � *
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Contractor Name Contractor Mailing Address
LUNDBERG ELECTRIC INC 16065 UNIVERISITY AVE. N.E. HAM LAKE, MN. 55304
Contractor Telephone Number Contractor E-mail Address Electrical Utility
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Contractor Author ed Sig ature Contractor License Number Job/Project Contact Pe n
� "ti�/. CA01129 GARY LUNDBERG
Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0- 400 an�ere �$35 New Service/Power Supply 0- 400 ampere @$35 3�
t� (
New Dwelling Service/Power Supply 401 - 800 ampere @$60
Up to 30 Feeders/Circuits - $100
New Home - More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A $6 Each
Other (Speafy)
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
Other (Specify)
(Specify)
0 - 400 ampere @ $35
( ) � $6 Each
New Service/Power Supply
New/Extended Feeders/Cir�
( 2 ) Feeders/Circuits
New/Extended Feeders/Circu
401 - 800 ampere � $60
:s - Up to 15 Feeders/Circuits
$6 Each or 16 to 30 �$100
- More Than 30 Feeders/Circui
ts UD 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 (Speafy)
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,
whichever is greater) whichever is greater) �, 5'�
Requests for Electrical Inspection (RE1) with a fee of $250 or less expire 12 months from the filing date. The contractor must have the work completed within
the 72 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 inspeded the electrical installation herein on the dates stated: For Department Use Only
Rough - In Inspection(s) Date ZO� ���� �� �� r f� n. ��oo�
r �
Final Inspection
This material can be made available in
TDD (651) 297-4198.
REI 02 (6/07)
Date
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such as large print, Braille or on a tape. To request, call 1-800
(DIAL-DLI) Voice or