P - 75396Minnesota Depart nt of Labor and Industry �
443 Lafay�tte Roa North
St. Paul, MN 55 n 5-4342
Phone: (651) 2$�`�-5064
TTY/MRS: (65 "j 297-4198
www.electrici state.mn.us
Contra or Re uest for Electrical Ins ection — One Famil Dwellin /Associated St
Date ^� Rough-In Inspection Required? Yes Single Inspection Other Than Rough-In: Re�
rn � p(
v Contractor Must Schedule All o� h-In Ins ections Contractor Must Schedule All Final Ins ections ill
Addres f Inspection — tr et CitylTownship Coun
`� 0 l s �� ��` ��
Owner Name Pr ject escnqtion � ��� J� �
� �-S ,��� � ���+�' P {.���i e �
Owner Telephone Number(s) — Include Area Code(s) / ���
ri
re
Schedule
� �.
� 3 -2 8�s' � � � � r �� � �
Contractor Name Contractor Mailing Address
To�-c�. �1 e.�.-�-t�i L � l� (�� �� c� o�'a�► o Sfi �G �31a� �_ MN
Contractor Telephone Number Contractor E-mail Address Electrical Utility ���
� � _ ' ��� c� �� 5 ?l'�l1 C.,Q_ ��\ — � P��(-'1C CArYI.:.�_ ._ W.. _
Con or Authori ed Si t Contractor License Number Job/Project Contact Pe on %�� _ t
� �� ��-� 1
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
New Dwelling Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home — More than 30 Feeders/Circuits (in addition to
ahnval ! 1 Feeders/Circuits Uo To 200 A Ca) $6 Each
Other
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
Other (Specify)
(Specify)
0 — 400 ampere @ $35
( ) @ $6 Each
Existing Home/Structure Remodel or Addition
New Service/Power Supply
New Service/Power Supply
New/Extended Feeders/Cin
ers/Circuits
0 — 400 �mpere @ $35
401 — 800 ampere @ $60
;s — Up to 15 F2ederslCircuits
$6 Each or 16 to 30 @$100
— More Than 30 F,e,eders/Circui
ts Uo to 200 A C�D $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 Feeders/Circuits ( ) @ $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, � J/�o
whichever is greater) whichever is greater)
Requests for Electricat Inspection (REI) with a fee of $250 or less expire 12 months from the flling date. The contractor must have.the work completed wRhfn
the 12 month period or submk another REI that includes the inspectlon fee for the uncompleted work. InspeeUon fees do not carry over from'one REI to
another.
A service eharge of $30 will be added for all dishonored checks.
I hereby certify thai I inspected the elecfical installation herein on the dates stated: For Departrnent Use nly
Rough — In Inspection(s) Date ��
Final Inspection
This material can b�
TDD (651) 297-4198.
oc n� �cm��
Date
�'
--'� (� t..i-�� . � r
available in different forms, such as ar
�' ' � . �' � � i
�_
n�lle or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or