P - 76727Minnesoia � nt of Labor and Is�dustry
443 Laiayette oad North
St. Paul, MN 5155-4342
Phone: (65 284-5064
TTY/AARS: 651) 297-d198
www.e ' .state.mn.us
Contractor R uest for Electrical
Date Rough-In Inspection Required?
� Contractor Must Schedule Atl Rou
/Address of Inspedion — S'treet
ownert�ar�n��� ���.G�. 15T
Owner Telep Number( ndude Area Code(s)
�/_? �f� '77 � �'�?�t�
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T�C� F � � .L � 2��8
tion — One Family Dwelling/Assa
Yes Single Inspedion Other Than Rough-In:
�ctions Co�trador Must Schedule Aq Finai Insoe�
Mailing Address
��P
/���.- � i2,�,,.-
�
G�
/
Structure
Ready Now
� Wilt Scheduie
� �--� Fee Calculation "
New Home or Associated Structure Existlng HomelStructure Remodel or Addition
New Dweliing Senioe/Power Supply 0— 400 ampere � S35 New Senrioe/Power Supply 0— 400 empere � S35
New Dwelling ServicelPawer Suppy 401 — 800 a�ere � S60 New ServicelPnwer S�phr 401 — 800 ampere Q S60
New DvMeNin9 FeedersiC'ucuits NewlE�dended FeederslC�wits — Up to 15 Feeders/CKCUits
�i^, :
Detached Garage or C�her Aasociated Structure
NeM+ Setv'�oe/Power Supply 0— 4U0 ampere � t35
New Feeders/CircuRs ( ) � 36 Each
A
( ) FeederslCircu� � S2 Each I
DetaChed Gerege Or Other ASSOCiBted ShuCture
New Servioe/Prnver Supply 0— 400 atnpere � t35
Nevr/Exte�ed Feeders/Circuits ( ) � 36 Each
Reconnected FeederslCircu�s ( ) � S2 Eac:h
Total (fhe iee catculated above or 335 multipiied Total (the Fae cakwlated abovoe or a35 multipiied
by the number of required inspeetion trips, by the number of required 'mspedion trips,
whichever is greatec) whichever is greater) c�r�"�'
Raques� for Elactrial i�petxton (RE� wifh a tae d S2r0 or tess acpke 12 moiMhs from the i�ng �e. The corMractor must I�re M+e wak coa�plaRed wk1Yn
m. u moMh pe�ioa or submk anoth.r REI nuR includes a�o xap.cnon f.e fo. n�s uncompNba wa1c.. x�specUoo rees ao rwc csny ov.. trom one REI �o
another.
A servics ehaepe of :SO wYl be adrMd for aN dhliorwerd Chsdcs.
� r�eBny certily tl�ac � inspeded n,e efectica� �staxe�ion rrerem o� n,e d�as atscea: For �.pa�cn�sne Use omy
Rough — In Inspec�ion(s) Date
Fina! Inspection -- // Date
--�.'"--c 2 -�z - �
Th1s maieiial can be rnade avaNable In dtfferoM forn�s. such as taryp
TDD (661) 287�418E.
REI 02 (6J07j
or on a tape. 7o request,
or