P - 75499Minnesota Dep rtment of Labor and Industry
443 Lafayette , oad North
St Paul, MN 155-4342
Phone: (65 284-5Q64
TlY/MRS: 1) 297-4198
www.ei ity.state.mn.us
Con ctor Re uest for Electrical Ins
Date Rough-In Inspection R�uired?
�'�c�' Contractor Must Schedule AII Rou h-In
Address of Ins�Ction — Streef
1C��1 ��� ����:(���
Br � eiepnvn� rvu�nwr��� — n n
� � � � ���
ra� {or Plame
tY1C,�� �,1._��..�I
rador Telephone Number
.�I?,� -��,c°�►�( _
;�
Corrtractor
tion — One Famil Dwellin /Associated Structure
y� Single Inspectlon Other Than Rough-In: Ready Now
�tiorts Contrador Must Schedule All Final Ins ons Will Schedule
CitylTownship �County �
�� � �� �� a
Project Descrip�on �
��.z..l t�4�-� ��� �-�'��� i�.�-�'
�� �S�..i.i tP�Q�9 '�'l C��C� �(� � C,�`�CI
�.J�C�.�� �i�� ��W� 1��� ��
ngAddress -� ` �
� v��rtc�c �. �� . . i�, �i�.� N���a� —
,
1c� ��e : � � �C � � d....
- --- _����„���
� Fee Caiculation w
New Home or Associated StruCture Existing Home/Structure Remodel or Addition
New Dwelltng Service/Poauer Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere �$35
New Dwelling Sen+i�/Powrer Supply 401— 800 ampere @$60 New Servic�lPower Supply 401— 800 ampere @$�0
N�,uv Dwellirta Feeders/Circuits New/ExtenderJ Feeders/Cira�fts — Up to 15 F�ers/Circuits
to 30 Feeders/Circuits -
Detached Garage or Other Associat� Structure
New Senrice/Power Supply 0-400 ampere @$35
New Fee.ders/CircWts ( ) (c3 $6 Eat�
$6 Each or 16 to 30 �$1 QO
— Mare Than 30 FeederslCi�cu
ffi Uo to 200 A Ca� $6 Ea�
�
( ) F�ders/Circufts � $2 Each �
Detached Garage or Other Associated Structure
Near Servic�/Power Supply 0— 40� ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Eech
Recwnneded Fe�ers/Circutts ( ) � $2 Each
��
Total (tF►e f� cala�lat� above or $35 multiplied Total (the fee cal�lated above or $35 multlpUed ����
by the number of required in.spection trips, by the number of rpuir� InsPection Mps, �
whichever is greater) whichever is great�)
Requesta for �ectricel lnspectlon (RRE� with a fee oi 5250 or I�s expire 12 months from Ure fllp�g date. The coMraetor must hare �►e woHc compteted within
the 12 manth ped� or submit another REI that Includ� the Insp�tlon t� tor the unmmp �tad work. Ins�ctlon i�s do not mrn► over from one REI to
another.
A service charge oi S30 wID be added tor aU ahonored checks.
i r,ereby cerary �t i u,s� tne ��c� in�maon nsrem on ure dace� sc�d: oe se oniy
Raugh — In lnspection(s) Date � �y�j � �
1 � �' � ��i
� V � �"�� �
This material can be made avallable in dNferent farms, such as large print, Braiqe or on a tape. To reque.at, catl 1-800-342-5354 (DIAL-DU) Voice or
TDD (651) 297-479&
REI 02 (6/07)