P - 76237Minnesota Depariment of Labor and Industry
443 Lafayette Roatl North
St Paul, MN 55;��5-4342
Phone: (651) 5064
TTY/MRS: ( ) 297-4196
vdww.eledri .state.mn.us
Contractor Re uest for Electrical Ins
�� Rough-In inspection Required?
�/��/o � Contractor Must Schedule All Rou h-In I
Address of Inspection — Street _
/ (� %�� S�'d���
Owmer Telephone Number( ) — Inciva
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Contractcr Name
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Co ctor Telephone Number
/' L1/_ � � 9, G�/x
�cro � u � 1 s 200'
o7�D`1-C�/�7�
tion — One Famii Dwellin /Associated Structure
Y� Single Inspection Other Than Rough-In: ❑ Ready Now
ections Cantractor Must Schedule All Final Insnections � Will Schedule
3�3 ��
New Home or Associated Structure
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Fee Calculation
. Plew Dwelling Service/Povsrer Suppy 0— 400 ampere @$35
New Dwelling Senrice/Power Supply 401 — 800 ampere �$60
- — Neve�elling FeedersiCircuits - — —
Uo to 30 FeedersJCircx�its - $10
New Home — More
To
Other
(in addifion to
Detached Garage or Other Associated Structure
Newr SenricelPower Supply 0— 4Q0 ampere @$35
New Feeders/Circuits ( ) � $6 Each
Other (Specify)
Other
�1�_ /`'d�..�c'�
T��Q� �� �5���
Electrical U 'I��
Existing Home/Structure Remodel or Addition
New Service/Power Suppy
Newr Senrice/Power Supply
New Feeders/Circuits — Up to
0 — 400 ampere r�8 $35
401 — 800 ampere @ $60
�
Qetached Garage or Other Associated Structure
New Senrice/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Rer.onnected Feeders/Circuits ( ) � $2 Each
,��
Total (the fee qlculated above or $35 multiplied Total (the fee calculated above or $35 multip"lfed
by tha number of required inspection trips, by the number of required inspectlon trips,
whichever is greater) �nrhichever is g�eater) ,��
Requests for Electrical lnspeetfon (REI) wffh a fee of $250 or less explre 12 mor�ths from the ftitng date. The coMractor must heve the work completed wfthin
the 12 morrth pe�lod or submtt another REI that includes the ins�on fee for the uncompieted work. lnspection fe� 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 inspected the eiectripl installation herein on the dates stat�: For Departrnent Use Only
Rough — In Inspection(s) Date
This material can be
TDD (651) 297-4196.
REI 02 (6/07)
Date
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:h as larqe p
or on a tape. To request, call 1-800-342-53b4 (DIAL-DLI) Voice or