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Minnesata De rtment of Labor and Industry
,443 Lafayett oad North
St. Paul, M 55155-4342
Phone: (6 284-5064
TTY/MRS' 651) 297-4198
www.elec city.state.mn.us
Contractor Re uest for Electrical Ins
Date Rough-In Inspection Required?
� Contractor Must Schedule All Rou h-In
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Telephone umber(s) —e
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,tor Name
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;tor Tele hone Number
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22940944
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:tion — One Famil Dwellin /Associate S ructure
Yes Single Inspection Other Than Rough-In: Ready Now
�ctions Contractor Must Schedule All Final Insaections ❑ Will Schedule
� Contractor Mailinc
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Contractor E-mail
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dress ` _ Electrical U
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umber Job/Project
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" Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0— 400 ampere @$35 New ServicelPower Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Dwelling Feede�s/Circuits New ended Feede�s/Circuits — Up to 15 Feeders/CircuKs /�
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addition to New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each P1ew/EMended Feeders/Circuits ( ) @ $6 Each
Other (Specify)
Reconnected Feeders/Circuits ( ) @ $2 Each
Total (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied
by the num6er of required inspection trips, by the number of required inspection trips, i
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of $250 or less expire 12 months from the ling date. The contractor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncom eted work. Inspection fees do not carry ove� from one REI to
another.
��N -- 7(�_� � A service charge of $30 will be added for all ishonored checks.
I hereby certify that 1 inspected the electrical installation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) Date -- � '?� _�o ���
Final Inspection
�
Thls materlal can be made
TDD (651) 297-4198.
REI 02 (6/07)
�
oate �� �IAR 1 �' 200�
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s, such as large print, Brallle or on a tape. To request, call 1-800-342-;
or