P - 75469Minnesota Depart�nt of Labflr and industry ��� �_�����
443 Lafayette d North
St Paul, MN 155-4342
PTTY/MRts (651�97-4198 I�CI.0 ���� �" 9 Loo7
unaw.el 'city.state.mn.us
Homeowner Re uest for Electrical� Ins ectibn
Date Rough-In Inspection Required? ❑ Yes Inspection OtherThan Rough-In: � Ready Novu
���"% � 0� Homeowmer Must Schedul� All Rou h-In Ins ctions Homeowner Must Sc�edule All Final Ins ctions Il� vv��l SG�edule
Address of lnspection — Street City/Township County
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Owner Name Project Desctipti
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Oumer Telephone ber(s) — InGude Area Code(s) � •
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Ov✓ner Mailing Address — Street City State Zip Code
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Owmer E-mail Address ...�. ��- Electrical U6I'
WOO d<<('00.S"�" � tY1A�� I� GON� C�
By signing this document, rtify that I am the ovmer as defined by Minn. Stat § 326.01 and wnll legally pertorm the electrical work
Owner Signature
,��r��'e- � .
u Fee Calculation
New Home or Associated Structure Existing HomelStructure Remodel or Addition
New Home Service/Pawer Supply 0— 400 ampere �$35 New Service/Power Suppiy 0— 400 ampere @$35
New Home 3e�vi ower upply 46'f =-SOQ ampere @$6� — - ew Senrics/�ourer Suppry � 401 = BOD grtt�ere �$60
New Home Feeders/CircUits New Feed�r�/Circuits — Up to 15 FeedersJCircx��its
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U to 30 Feeders/Circ�its -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Ci�cuits (in addition to � w Feeders/Circuits — More Than 30 Feeders/Circuits
above Feeders/Circ�its U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) . Reconnected FeedersfCircuits
� 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— 4U0 ampere �$35
New FeedersJCircuits ( ) @ $6 Each New Feeders/Circuits ( ) @ $6 Each
Other (Specdy) Reconneded FeederslCircuits ( ) @ $2 Each
Other (Specify) Other (Specify)
o�i �@�D %�.
Total (the fee calculated above or $35 multipiied Total (the fee calculated above or $35 multipiied �'�
by the number of required inspedion trips, , by the number of required inspectlon trips,
whichever is greater) whicfiever is greater) ,
Requests fw Electr(cal Inspectlun (REI) with a fee of $250 or less expire 12 mo�rths from the flifng data. The owner must have the work ple ffhin the
12 month pe�lod or submit anotF�er ttEl that includes the i�pectlon fee for the uncompleted work. InspecUon fees do not carry over m one to other.
A service cha e of $30 wltl be added for all dishonored checks.
I hereby certiiy fhat I fnspected the etectrical instaliation herefn on the dates stated: For Department Use O 1
Rough — In Inspedion ) Date
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Final inspection Date �
d �3-�d
This material can be made available in dffferent forms, such as larlle orint Brallle or on a tape. To request, call 1-640-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.
REI 01 (6/0'n