P - 76675Minnesota De a ent of Labor and Industr ,�j /
443 Lafayette R d North Y °' ✓�)`� ��� `��
St. Paul, MN 55-4342 �� OC"r 3 1 �foo�
Phone: (651) 4-5064 1 L
TTY/MRS: 1) 297-4198
www.electri y.state.mn.us
Contractor Re uest for Electrical Ins ection — One Famil Dwellin /Associated tructure
Dat Rough-In Inspection Required? ❑ Yes Single Inspection Other Than Rough-In: Ready Now
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� Contractor Must Schedule All Rou h-In Ins ections Contractor Must Schedule All Final Ins ections ❑ Will Schedule
Ad ress f Ins ectio�j Street City/T wnship County
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Owner Telephone
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Project Description
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Contractor Mailing Address
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Contractor E-maiTAdd s
Contractor License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60
New Owelting Feeder�7Circuits
Up to 30 Feeders/Circuits - $100
New Home — More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A@$6 Each
Other (Specify)
Detached Garape or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (Specify)
Other (Specify)
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Job/Project q��►�ta��t
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Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New tended Feeders/Circuits — Up to 15 Feeders/Circuits
� Feeders/Circuits $6 Each or 16 to 30 $100
New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
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
Other (Specify)
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Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied �
by the num6er of required inspection trips, by the number of required inspection trips,
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of $250 or less expire 12 months from the filing date. The contractor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of 530 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates
Rough — In Inspection(s) Date
Finallnspection �--'
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This material can be made available in
TDD (651) 297-4198.
REI 02 (6/07)
Date
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Department Use Only
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print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
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