P - 76945Minnesota Dep nt of Labor and Industry
4d3 Lafayette d North
St. Paul, MN 155-4342
Phone: (65 84-5064
TTY/MRS: 51) 297-4198
www.elect 'ry.state.mn.us
Cont ctor Re uest for Electrical
te � Rough-In Inspection Required?
V Contrador Must Schedule All Rou
A d _c.a f Insr�r2ien - Strnpf
Name
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Tele�hon
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er(s Indude
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tion — One Famil Dwellin lAss�
Yes Single Inspedion Other Than Rough-In:
�ctions___ Contr'actor Must Schedule All Final Insa
�tructure
Ready Now
Will Schedule
I'� I���,,, " Projed:Description 1
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ctor h ri�ed Signatu Contractor ' nse 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 Dwelling Feeders/Circuits
Up to 30 Feeders/Circuits - 51 a
New Home - More than 30 Feeders/Circuits (in addition to
above ) Feeders/Circuits Uu To 200 A Caa S6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other
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Existing Home/Structure Remodel or Addition
New Service/Power Supply 0- 400 ampere @$35
New Service/Powe� Supply 401 - 800 ampere @$60
New F ederslCircuits - Up to 15 Feeders/Circuifs
eeders/Circuits a� $6 Each or 16 to 30 � 5100
New Feeders/Circuits - More Than
200 A
( ) FeedersJCircuits $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @ y35
New Feeders/Circuits ( ) @ $6 Each
Reconnected FeedeFs/Circuits ( ) @ $2 Each
Other (Sqecifv)
Total (the fee cafculated above or $35 multiplied TOtel (the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection trips,
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REQ wlth a fee of S250 or less expire 12 months from the flling date. The corrtractor must have the worlc completed within '
the 12 morrth perlod or submit another REI that includes the inspecdon fee for the uncompleted worlc. I�specHon 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 1 inspected the elecUiql installation herein on the dates stated: For Department Use Only
Rough - In Inspection(s) Date
i nIS matenal can bi
TDD (651) 297-4198.
REI 02 (6/07)
- /a� 9-�
forms, such as large
ereille or on a tape. To request,
or
.