P - 75569Minnesota Depa�tment of Labor and Industry
.443 Lafayette Ro�North
St. Paul, MN 55-4342
Phone: (651 84-5064
TTY/MRS: 51) 297-4198
www.ele city.state.mn.us
Contractor Re uest for Electrical Ins
��te_ ^� Rough-In Inspection Required?
ll �'d° Contractor Must Schedule All Rouah-In
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tion — One Fam
Yes Single Inspecl
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�C'D � A N � � 200�
Dwellina/Associated
Contractor Must Schedule All Final Ins ctions
City/ ow ship County
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Project Description --
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Contractor Mailing Address
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Contractor L' n e Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Suppiv 0— 400 ampere (a� $35
New Dwelling Service/Power Supply 401 — 800 ampere @$60
Up to 30 Feeders/Circuits - $
— More than 30 FeederslCircuits (in addition to
) Feeders/Circuits Up To 200 A C�D_ $6 Each
Detached Garage 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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Electrical Utility
Ready Now
Will Schedule
Existing Home/Structure Remodel or Addition
New Service/Power Supply
Newr Service/Power Supply
0 — 400 ampere @ $35
401 — 800 ampere @ $60
— Up to 15 Feeders/Circuits
30
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/E�ctended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
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 Etect�ical Inspectio� (REI) with a fee of $250 or less expire 12 months from the flling date. The contractor must have the work completed within
the 12 month period or submit another REl that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
enother.
/���/ �_� r. �b'� A service charge of $30 will be added for atl dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: For DepBrtment Use Only
Rough — In Inspection(s) Date e
na
This mate►lal can b�
TDD (651) 297-4198.
REI 02 (6/07)
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such as lar�e a
or on a tape. To request, call
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or