P - 76749Minnesota De rtment of Labor and Industry
443 Lafayett Road North
St. Paul, M 55155-4342
Phone: ( 1) 284-5064
TTY/MR (651) 297-4198
www.ele riciry.state.mn.us
ContractorlRe istered Em I
Date Rough-In Inspection Required? �y j �
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Address of Inspection - Street
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Owner Name/")
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Owner Telephone Number(s) - Include Area Code(s)
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►er Re uest for Electrical Ins ection
Ye5 Single inspection Other Tha� Rough-In Read�
�tions ContractorlEm lo er Must Schedule Ail Final Ins ection Wiil S
CityfTownship Cou y
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Project Description
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Contractor/Registered Employer Name ContractoNRegistered Employer Mailing Address , ,
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ContractorlEmployer Telephone Number Contractor/Employer E-mail Address Electrical Utility
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r ctor/Employer Au�horiz Signature Contractor License Number J o�ed Contact Person
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Fee Calculation
Service/Power Supply
ServicelPower Supply
0 - 400 ampere @ $35
401 - 800 ampere @ S60
Service/Power Supply Above 800 ampere @$100
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NewlExtended Feeders/Circuits Up To 200 A( ) Q S6 Each �, f-�!%
Feeders/Circuits Above 200 A
Reconnected Feeders/Circuits
0
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Manufactured Home Park Lot Supply (
Recreational Vehicle Site Supply Equipment
( ) Circuits Originating in the Equipm
Street, Parking Lot, Lighting Standard (
Tech�ology System Devices (
Separate Bonding Inspections for Swimr
Equipotential Planes (
Center Pivot Irrigatio� Booms (
Plus ( ) Electrical Drive
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Luminaire Retrofit Modifications (
) @ $15 Each � Concrete-Encased Electrode Inspection (
Investigative Fee $70 Or The Total Inspe
) @ $2 Each ;
Whichever Is Greater U To $1,000
Special Inspection Fee ( ) Hours
)@$35 Each � plus Miles The IRS Mil
Other
Q $6 Each
) @ $5 Each
Transformers Up to 10 kva ( ) Q$15 Each
) Q 75Q Each
�g Pools and
) � $35 Each
) @ $35 Each
nits @ $5 Each
) @ 25¢ Each
) Q $35 Each
Hour
of (
Over 600 Volts — nad me comomea serv�ce�aower suppy ana reex.idrourt ree to
resutt i� Ooubk the regular fce �Coes rwt aDP�Y ro electric sgn and outline IgMmgl
( ) New Multi-Family Dwellings @ $70 Each
With Up To 20 FeederslCircuits
Transformers Over 10 kva ( )@$30 Each ( ) Addi onal Gircuas Above The 20 Allowed Per Unit�
6 Each � � � '"�
Electnc Signs and Outline Lighting TOtAI (the fee calculated above or $35 multipli
Transformers/Power Su lies $5 Each by the number of required inspection tnps, �� �
whichever is greater)
Requesta for Elect�ical Inspection (REI) with a fee of 5250 or less expire 12 months from the filing date. Tha contractorlemployer must have the
completed within the 12 month period or submit anothe� REI that includes the inspection fea for the uncompletad woAe. I�spection fees do not cs
from one REI to another.
A service char e of S30 will be added for atl dishonored checks.
1 hereby certlfy that I mspected the electrical installation herem on the dates stated: For D@pe►'tment Use Only
Rough - In Inspecti s'/�� ,, Date
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Final tnspection �
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