P - 75646Minnesota De
443 Lafayette
St. Paul, MN
Phone: (651)
TTY/MRS: (6
W1NW.@I@C�nCI
� Contra�
�nt of Labor and Industry
North � '
297-4198
ate.mn.us
r Re uest for Electrical Ins
Rough-In Inspection Required?
Contractor Must Schedule Atl Rou h-In
�tinn _ C4roa4
Name —
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T phone Number(s) –
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:tor Name
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:tor Telep one Number
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�tion — One Famil Dwellin
Yes Single Inspection Other Than
�ctions Contractor Must Schedule All
. Project aescriptibnl \
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� Contracto Mailing Addre
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Contractor E-mail Hddress Electrical Utility
Cont�actor License Number Job/Project Contact P�ers
►jructure
Ready Now
Will Schedule
i�
� Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Owelling Service/Power Supply 0– 400 ampere @$35 New ServicelPower Supply 0– 400 ampere @$35
New Dwelling Service/Power Supply 401 – 800 ampere @$60 New Service/Power Supply 401 – 800 ampere @$60
New Dwelling Feeders/Circuits New/�tended Feeders/Circuits – Ua to 15 Feeders/Circuits
Up to 30 Feeders/Circuits -
New Home – More than 30 Feeders/Circuits (in addi6on to
above) ( ) Feeders/Circuits Up To 200 A $6 Eac
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (Specify)
Other (Specify)
$6 Each or 16 to 30 @$100
– More Than 30 Feeders/Circu
its Up to 200 A C� $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
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TOtal (the fee calculated above or $35 multiplied Tot81(the fee calculated above or $35 multiplied _'�C �
by the num6er of required inspeetion trips, by the number of required inspection trips, ��J U
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of 5250 or less expire 12 months from the flling date. The contractor must have the work compieted wkhi�
the 12 month perlod or submit another REI that i�cludes the inspection fee for the uncompleted work. lnspectfon fees do not carry over from one REI to
another.
A service charge ot E30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: For Dep8ltment Use Only
Rough – In Inspection(s) Date
Final Inspection Date
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This material can be made available in different forms, such as lar
TDD (651) 287-4198.
REI 02 (6l07)
Zab�'����y
�cro �u� �s �oo�
or on a tape. To request, call 1-800-342-5354
or