P - 76964Minnesota Dep ent of Labor and Industry
443 Lafayette ad North
St. Paul. MN 155-4342
Phone: (65 84-5064
TTY/MRS: 51) 297-4198
�n�ww.elec ity.state.mn.us
�ontractor/Registered Em
Date I Rough-In inspection Required?
�✓� ��� � Contractor/Employer Must Schedule Ail Rough-In
Address of Inspection - Street
S 5 � � � _C'l��!!�,�,�
Ob+ner Na�e —
J l i ._ � . ,r1 r
rn,�;� ��� � �
� W ! — �/ l.Y-���
REC'D S E P 10 200i
rer Re uest for Electrical Ins ection
Yes Single Inspection Other Than Rough-In:
Ready Novq
�tions IContractor/Employer Must Schedule All Final Inspections ❑ Wiil Schedule
� CItV�OWfishin r......a,.
Projecf
—_ --
Owner T lephone Number( - Include Area Code(s) —�
�1 � �� .- Y3� ;
Cont or/ gistered Em loyer Name I Contractor/Registered Employer Mailing
'�` ; t a.�2v � � �� C
ContractorlEmployer Telephone Number � ContractoNEmployer E-mail Addres
���`�'�� ���b ��z7�g-ao�� � �
tractor/ mplo er Au horized Signature Co ractor License Number �
� �Q�Y71 y , �1 rn 4�5 � �l
�ee Calculation
Service/Power Supply
Service/Power Supply
Service/Power Supply
0 - 400 ampere @ S35
401 - 800 ampere @ �60
Above 800 ampere @ 5100
New/Extended Feeders/Circuits Up To 200 A( )@$6 Each
--- FeedeisLCircuits_Atin+re 2�Q A ( i� S1 � Eash -
Reconnected Feeders/Circuits ( ) @ �2 Each
Manufactured Home Park Lot Supply (
Recreational Vehicle Site Suppiy Equipment
i ) Circuits Originatinq in the Equipm
) @ S35 Each
nt @ S6 Each
55Y3,2, ' ' -
i
� 1! ,/ ,
lt.,.� �- l '4-'t /T {�-'1'
e�;� i�1,�. SS31.
lectrical Utilitv
Contact Person
.� � �� �� 9 �v
Technology System Devices (
Separate Bonding Inspections for Swimr
Equipotential Planes �
Center P�vot Irrigation Booms (
Plus ( ) Electrical Drive
Luminaire Retrofit Modifications (
) @ 75¢ Each
g Poois and
) @ �35 Each
) @ �35 Each
) @ 25¢ Each
�encreYe-Er�cased €lec�rocie fnspeetrori { ) � �35 Eacfi
Investigative Fee �70 Or The Total Inspection Fee,
Whichever Is Greater Up To �1 000
Special Inspection Fee ( ) Hours @$80 Per Hour
P��� ( • ) Miles The IRS Milea e Rate of (
Other
Street. Parking Lot, Lighting Standard ( )@ S5 Each I OVQf BOO VOI(S — Atld the combined service/po�ver suppty antl feetle�/urcuii fee to i
__ _ ' resWt in double the regular fee (does not apply to clecMC sgn antl out�ine lighting)
Transformers Up to 10 kva ( )@�15 Each � ) New Multi-Family Dwellings @$70 Each
i
-- ----- With Up To 20 Feeders/Circuits ;
Transformers Over 10 kva ( )@�30 Each � ( ) Additionai Circuits Above The 20 Allowed Per Unit ,
S6 Each
Electric Signs and Outline Lighting � TOtdl (the fee calculated above or �35 multiplied
( ) Transformers/Power Sup Ip ies S5 Each � by the numbe�r of requ�r�d.insp �c�n trips, �� �� `�
whichever is reater � �
Requests for Electrical Inspection (REI) with a fee of 5250 or less expire 12 months from the filing date. The contractor/employer must have the wori:
completed within the �2 month period or submit another REI that i�cludes the inspection fee for the uncompleted work. Inspection fees do not carry over
from one REI to another.
A service charqe of $30 will be added for all dishonored checks.
I hereby certify ihat I inspected the electrical instalia6on herein on the dates stated: For Department Use Only
Rough - in Inspection(s) Date
-- ----- -- — ---
F Ilnspection Date !
�[' � �� � ��'� 7 ' • -
_ —_. __ _
I
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4'19g,
REI 03 (6/071 -