P - 75185-`� Minnesota Depa r�errt of Labor and industry � /��
443 Lafayette d North �"'" � �� �
st. Pe��, "'" ��2 � REC'D J A N 17 200�
Phone: (651 84-5064 ,
TTY/MRS: 1) 297-4198 � �
wuvw.el �+.state.mn.us , __, �
Cont ctor Re uest for Electrical Ins ection - One Famil Dwell6n /Associated Structure
Da�e � Rough-In Inspection Required? es Single Inspection Other Than Rough-In: � Ready Now
Atl// Contractor Must Schedule All Rou h-In Ins ections Contractor Must Schedule al l F i n a l I n s c 6 o n s ❑ W i l l S c h e d u l e
d t e s s� In� on — Street C' PToranshi Co
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wner Name � 1 Project Descriptio , �
cQc s � l C�. ��` �
Owner Telep ne Number s) I clude Area Code(s)
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Co�rtractor Name Contrador Mailing Address
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Contractor Telephone Num er Contrador E-mail Address Electrical Util' .
�'� � '- �� O ` t `��S � �l�c.� � � �-��' � ^ � ��:�'�1
Contra o A ' ed Signature Contractor License Number Job/Project Contact Person
► � � '� � � 1 f'1
Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition .
New Dwelling Service/Power Supply 0— 400 ampere �$35 New Service/Power Suppl�� 0— 400 ampere �$3� '3��.
New Dwelling Service/Power.Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Darelling Feeders/CircuitsA ' New/Extended Feeders/Circuits — Up to 15 Feeders/Cirr.uits ���
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Ea�h or 16 to 30 $100
New Home - More than 30 Feeders/Circuits (in addition to New/Extended Feeders/Circu'its — More Than 30 Feeders/Circuits
Feeders/Circuits $2 Each
Deftached Garage or Other Associated Structure Detached Garage or Other Associated Structure
. New Servic�/Power Supply 0— 400 ampere @$35 • New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each New/Extended Feeders/Circuits ( ) @ $6 Each �
Other (SPeafY? _
Recronnected Feeders/Circuits ( ) @ $2 Each
Other (S�dfy) Other (Specify) �
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TOt81(the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied �
by the number of r�uired inspection trips, by the number of required inspection trips,
whichever is greater) whichever is greater)
Requests for Elec4r�cal l�pecdon (REq with a fee of $260 or less explre 12 months from the flling dete. The contr�ac4or must have the work completed withln
the 12 month perlod or submR another REI that includes the tnspecdon fee for the uncompleted work. Inspection fees do not carry over irom one REI to
' another.
A seroice charge of $3D wtll be added for all dishonored checks.
I hereby certtf�+that I inspected the ectriql installa�on herein on the dates stated: • For Departrnent Use Only
Rough — In Inspe ' n(s) Date
�u�- l l%— d�
" Finallnspection� �� Date
� �—��
Th(s materPal caln be made available in differerrt forms, such as large print, Bretlle or on a tape. To request, call 1�00-342-5354 (DIAL-DLI) Voice or
TDD (651) 297•4196. .
oc� no iamr .