P - 75571Minnesota De( �` rtment of Labor and Industry
443 Lafayett +�toad North
St. Paul, M �55155�342
Phone: (6 ,, 284_5064
TTY/MRS' (651) 297-4198
www.ele 'city.state.mn.us
Co actor Re uest for Electrical Ins
e Rough-In Inspection Required?
� u Contractor Must Schedule All Rou h-In
4ddress of Inspection _ Street
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Telephone Number
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Auth ize Signature
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Contractor
Yes
— One Family Dwellin
Final
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roject Description
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.-mad Address Flarfrinal I 14i1i4v
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❑ Will Schedule
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New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0– 400 ampere @$35 New Seroice/Power Su I
PP Y 0– 400 ampere @$35
New Dwelling Service/Power Supply 401 – 800 ampere @$60 New Service/Power Supply 401 – 800 ampere @$60
New Dwelling Feeders/Circuits
�
New ended Feeders/Circuits – Up to 15 Feeders/Circuits �
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100 /"`�'
Home – More than 30 Feeders/Circuits (in addition to New/Extended Feeders/Circuits – More Than 30 Feeders/Circuits
e Feeders/Circuits U To 200 A $6 Each
r(Specify) Feeders/Circuits U to Z00 A $6 Each
Reconnected Feeders/Circuitc
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
reeoersit;ircwts $2 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Total (the fee calculated above or $35 muitiplied Total (the fee calculated above or $35 multiplied
by the nurti6er of required inspection trips, by the number of required inspection trips, `=�
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of E250 or less expire 12 months from th filing date. The contracto� must have the work completed withi�
the 12 month period or submit another REI that includes the lnspaction fee for the unc pleted work. Inspection fees do not carry over irom one REI to
another.
�C �(� � �., 7� , � a' A service charge of $30 will be added for Ii dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated:
Rough – In Inspection(s) ���,�lepartrr�ent � �n�
Date �� � `� (
�
F' allnspection �� nuG q� A00�
Date � /� 1 L
�`�'�'�'� �
This material can be made available in different forms, such as large print, Braflle or on a tepe, To request, call 1-800-342-535
TDD (651) 297-419H.
REI 02 (6/07)
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