P - 75641Minnesota Depart��nt of Labor and 'ndustry .
443 Lafayette R' d North .
SG Pa�i, iv1N i55-4342 .
Phone: (651 84-5064
TTY/MRS: 1) 297-4198
www.el ty.state.mn.us
Contr ctor Reguest for Electrical I
Dat j Rough-In Inspection Reqwred?
�1 � I Contractor Must Schedule All Rougl
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Owner Name ��
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elephone Number(s�
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j S�ngle Inspection Other Than Rough-In: Ready Now
Contractor AAust Schedule All Final Ins ections ❑ Will Schedule
City/ -swnship Co nty
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Pro�ect Descnption
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ii atyre Contractor License Number
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• � Fee Calculation �
iVew Home or Associated Structure
New Dwelling Servlce/Power Supply 0-�i00 ampere,@ �35
New Owelling Serwce/PowerSupply a01 - S00 ampere @ 360
New Dwelling FeederstCircwts �
Up to 30 Feeders/Circuits - 310
New Home -�llore than 30 Fesders/Circuits (in addition to
above) f 1 Feeders/Circuds Up To a00 A@$6 Each �
Other (Spec�fy) —
Utility
�t Contact Person
Existing Home/Structure Remodel o� Addition
New ServicelPower Supply 0- 400 ampere (� �35 I
New Service/Power Supply 401 - 800 ampere @ P60
New/Extended Feeders/CircwLs - Up to 15 FeederslCircuits
( ) Feeders/Circuits �$6 Each or 16 to 30 � 5100
�ie...ic„�o.,.�� Foa,nwrc�rircuits — Mere Than 30 FeBdeB/CuCw
Reconnected
A C� $6 Each
: �_ � ) Feeders/Circuits C�D SZ Each I
Detached Garage or Other Associated Structure Detached Garage or Other Associated SWcture
New Service/Power Supply 0- 400 ampere �$35
New Feeders/Circuds ( ) @ $6 Each
Other (Specify) '
Other(Specify) - - --------
New Service/Power Supply 0- 400 ampere � S35
New/Extended Feeders/Circuits ( ) @ $8 Each
Reconnected FeederslCircuds ( ) � $2 Each
-- —• Other (SPeafy)
-�,
7otel (the fee calculated abave or $35 muldplied Total (the fee calculated above or $35 multiplied
by the number of reqwred inspection tnps, by the number of required inspection trips, , C��
whichever is greater) whichever is greater)
Requests for Electrical Ins�cdon (REI) with a fee of $250 or leas expire 12 montha from the filing date. The contrector muat hare the work completed ' in ,�q0
the 12 month period or submrt another REI thet includes the inspection fee for the uncompleted work Inspaetion fees do not carry over from one REl t�� r`�(�
another.
A service cnarge of S30 will be added for all dishonored checks.
I hereby certdy that I inspected the electncal installaQan herein on the detes stated i � For Departmer�t Use Only
Rough - In Inspection(s) Date
Finallnspection � Date
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This material can be made available in different forms, such as large prin
TDO (6b1) 297-4188.
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;'��.� REC'D - A U L 01 2008
t, Braille or on a tape. To requ�t, call 1-800-342-5354 (DIAL-DLI) Voice or