P - 75563Minnesota Departm t of Labor and Industry
443 Lafayette Roa,- orth
St. Paul, MN 551 -4342
Phone: (651) 2 5064
TTY/MRS: (65 297-4198
www.electrici state.mn.us
Contra or Re uest for Electrical Ins ection — One Famil Dwellin /Associated Structure
��� 7� Rough-In Inspection Required? ❑ Yes Single Inspection Other Than Rough-In: Ready Now
� � Contractor Must Schedule All Rou h-In Ins ections Contractor Must Schedule All Final Ins edions ❑ Will Schedule
Address of Inspedion — Street Citv/Townshin r,,,,.,�.,
Own r Name
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Owner Telept
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Contractor Na
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Contractor Te
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`-t' c�-�-� .
ne Number
Signature
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Contractor E-mail Address Electrical Utility
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ontractor License Number Job/Project Contact Person
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Fee Calculation
New Home orAssociated Stru'cture Existing Home/Structure Remodel orAddition
New Dwelling Service/Power Supply 0- 400 ampere @$35 New Service/Power Supply 0- 400 ampere @$35
New Dwelling Service/Power Supply 401 - 800 ampere @$60 New Service/Power Supply 401 - 800 ampere @$60
New Owelling Feeders/Circuits • - New Feeders/Circuits - l;p to 15 FeedersiCircuits
Home — More than 30
a
) Feeders/Circuits - $100
�cuits (in addition to
To 200 A (c� $6 Each
Detached Garage or Other Associated Structure
New ServicelPower Supply 0- 400 ampere @$35
New Feeders/Circuits ^ ( ) @ $6 Each
Other
� i reeaers��ircuits C� $6 Each or 16 to 30 an $100
�l�w Feeders/Circuits - More Than 30 Feeders/Circufts
( ) Feeders/Circuits Up to 200 A S6 Each
Reconnected Feeders/Circwts
Detached Garage or Other Assoclated Structure
New Service/Power Supply 0- 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Fteconnected Feeders/Circuits ( ) @ $Z Each
Tot81 (the fee calculated above or $35 multiplied ' TOtai (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 Inspecdon (REI) with a fee of 5250 or less expire 12 months from the flling date. The contractor must have the woric completed withfn
the 12 month period or submit another REI that includes the fnspection fee tor the uncompleted work. Inspectlon fees do not carry over from one REI to
another.
• A serv(ce charge ot E30 wfll be added for all dishonored checks, �
I hereby certily that I inspected the elecVical installation herein on the dates stated:
Rough - In Inspection(s) For Department Use Only
Date , � "�� n� �0 j'� �
V !�
Final Inspection ate ���p AUG 2 7 08
, �' �
This material can be made availabte in dlNerent forms, such s large prin , greille or on a tape. To request, cali 1-80 342-53 (DIAL-DLI) Vofce or
TDD (651) 297-4198.
REI 02 (6/07)