P - 76718Minnesota Depa ent of Labor and Industry
443 Lafayette R No�th
St. Paul, MN 5 55-4342
Phone: (651) -5064
TTY/MRS: 1) 297-4198
www.electri .state.mn.us
Contractdr Re uest for Electrical Ins
Date Rough-In Inspection Required?
� � � Contractor Must Schedule AII Rou h-In
Address of Inspection — Street
ame
Owner Telephone N
Contractor Name
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�ection — One Famil Dwellin /Associated Structure
� Yes Single Inspection Other Than Rough-In: � Ready Now
ns ections Contractor Must Schedule All Final Ins ections Will Schedule
City/Township County
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Project Descriq��/���
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— Include Area Code(s) � �� � � _
Contractor Mailing Address
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r Contractor E-mail Address
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Contractor License 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 - $100
lome — More than 30 Feeders/Circuits (in addition to
)( ) Feeders/Circuits Up To 200 A $6 Each
{Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (Specify)
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Electrical Utility
Job/Project Contact Person
Existing Home/Structure Remodel or Addition
New Service/Power Su� �— 400 ampere @$35 �
a
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
Feeders/Circuits $6 Each or 16 to 30 $100
New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
7i Feeders/Circuits U to 200 A $6 Each �
Reconnected Feeders/Circuits
� � Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
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Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
3��Uo
TOtal (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied � �)
by the number of required inspection trips, by the number of required inspection trips, Z�ISV
whichever is greater) whichever is greater)
Requests for Electrical I�spection (REf) with a fee of 3250 or less expire 12 mo�ths from the filing date. The contractor must have the work completed within
the 12 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 charge of 530 will be added for all dishonored checks.
I hereby certify that 1 inspected the
Rough - In Inspection(s)�„
Final Inspection
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This matertal can b�
TDD (651) 297�198.
REI 02 (6/0�
mstanation nerein on tne dates stated:
Date
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Date
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different forms, su— c�'s large prir
For
or on a tape. To request, call 1
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Voice or