P - 75353.y
Minnesota �partrn " of Lahar and Industry
443 Lafayette Ro orth
St. Paul, MN 55 342 •
Phone: (651) 5�4
TTY/MRS: ( ) 29T-4198
www.eled ' .state.mn.us
Contractor Re uest for Electrical 1
Date Rough-tn Inspedion Required7
Contractor Must Schedule All Rou I
Addre�s of Inspedion — Street /1 . .
Name
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i or Telephone Numbe�
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tion — One Famil Dwell
Yes Single Inspedion Other Th�
Ready Now
Will Schedule
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itractor Mailing Address
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itractor E-mail Address ElecViql UGlity
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itrador Uoense Num Job/ProJect Contact Person
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� Fee Calculation
New Home or Assoclated Structure Existi�g Home/Structure Remodel or Addition
New Dwelling Service/Powrer Supply 0— 400 ampere (g� a35 New Service/Power Supply 0— 400 ampere (QP $35
New DwelNng SeroicelPower Sup�ly_401 — 800 ampere (� 360 New Service/Power Supply 401 — 800 am�re �$60
New Dwelling Feeders/Circuits New Feeders/Circuits — Up to 15 Feeders/Cireuits
W� to 30 Feeders/Circufts - 1Q0 Feeders/Cirarits a6 Each or 18 to 30 100
New Home — More than 30 FeederslCircuits (in addition to New FeederslCir�wits — Mora Than 30 FeedetsfCircuits
abova • Feeders/Circuits U Ta 200 A 36 Each _) Feeders/Circuits UD to 200 A aCD. �6 Each
. I
Detached Garage or Other Assocfated Structure
New Service/Power Suppiy 0— 400 ampere (Q� S35
New Feedero/Circuits ( ) (� a6 Eech
Detached Garage or Other Associated Structure
New Servlce/Power Supply 0— 400 ampere (p� $35
New Feeders/Circutts ( ) (r� �6 Eac#i
Reconneded FeederaJCircuits ( ) (� a2 Each
r�
TOtal (the fee calculated above or 535 multiplied Totel (the fee calcwlated above or a35 mu(tiplied �
by the number o! required inspection Vips, by the number of required inspecNon trips, �%�� ��� �
whichever is greater) whichever is greater) l
Requeaq for Elactrlcsl inspection (REI) with a fee of S2S0 or laas expire 12 months trom tha flling date. The cornractor mtrot have tha �vork completed w n
the 12 month pe�lod ov suSmH another REI that Insludes the Inapaetloo fee for the uncompleted woNc. Inapectlon faes do not cerry over Trom ona to
_ another.
A sarviee efarge of s30 wlll be added for alt dlehononad checks.
I hereby cerGy that I inspected the elactrical instelladon hereln on the dates stated: For Dapartment Use Only
Rough — In Inspedion(s)� Date
� �� �� � a� `o��
Final Inspection Date
�: �-?-� � REC'p J UN 1. 0 2008
Thla m�terlal csn bs mads awliable In dfiterent fortr�, such as Isrge pdnt, Braille or on a tape. To reques; call 1-800-342-6354 (DIAL-DU) Volce or
TDD �661) T87�198.
REI 02 (8/07)