P - 75723mpu�tssuw uesparuu�n� � �rauur arw inuusuy
443 Lafayette Road
St Paul, MN 559 342
Phone: (651) 5064
7TY/MRS: ) 297-4958
wwwr.ele .state.mn.us
Contractor Re uest for Elec�trical
Dat Rough-In InspecUon Required?
�`�v ` Cantractor Must Schedule All Rou
Addross of Insp�ction � Street
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Contractor Name
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Contractor Telephone Number
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Contractor Authorized Signature
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#ion — �ne Famit Dwellin /Associated Structure
y� Single tnspection Other Than Rough-In: Ready Now
�tions Contractar Must Schedule All �inai Insnectior� ❑ Will Schedule
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Cantractor Mailing Address
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Contractor E-mail Address
Contrador Liaense Numbar
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New Home or Associated Structure
Ne�r D�roellirtg S�roice/Power 8upply 0— 400 am�re �$35
Fee Calculation
H�uv Qwelling Service/Po�ver Supply 401— 800 ampere @$60
Rtew Hame — More than 30
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to
D�stached (�airage or Other Associated S�ructur�
N�dr Service/Potiroer SuPP�Y
New Feeders/Circuits
0 — 400 empere @ $35
( ) (c� $6 Each
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County
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�oject Contact Person
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Existing HomefStructure RemOdel or Addition
New Service/Power Supply 0— 400 ampere @$35
Wewr Senric�/Power Supply 401— 800 am�re @$60
N�w/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
Fe�ers%Circu�s �Each or 16 to 3D $1�b
Nlawl�rtami�rl Graw�iarc/(:irn�ih¢ _ Mroa Than 3A Ftar+ariara/Circui
�ch� C3ar°age or Other Associat�d Strudvrse
Nc�vu ServicB/Pawer Suppiy 0— 400 ampere �$35
New/Extended Feeders/Circ�its ( ) � $6 Each
Reconneded Feedera/Ci�uits ( ) @ $2 Each
Ti�al (the tee cah:ulat� above or $35 mut�pl'� Total (ihe f� calcula�ed above or $35 multiplied " o
by the number of required inspedion trlps, by the number o# required 6�s�c�on trips, ""�(j
�rhichever is greater) whfchever is greater)
Raqueabs tor Elettrlcal InspecHan (REQ wltt� a tes of f28� � lese expire 12 months from the flpne date. The eontractor mqst have the work complpted witlf6�
the 12 mornh periad or submit another REI tha't includes the Inapection tee for �e uncompleted wo� InapacNan teea do not aarrlt over hom one RB !a
\anotl�er.
, n servfas cnarge or 83o wi�� I� eaded ror al� d�s�wnored cnecke. �o��
1 hereby ceAity at I inspecied the efectrical instaliation herein an the dates stated: For DepeltmeM US� Only
Rough — i pectio ) �G t!'� $'- `�a�!
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ihis matf�rtal can 1� mad�
Tpp (8S1) �7-4198.
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such 8s larqe pr6tt� Braflle or on a tape.
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