P - 76726Minnesota Dep ent of Labor and Industry
443 Lafayette ad North
St.� Paul, M 5155-4342
Phone: ( 284-5064
TTY/MR (651) 297-4198
www.e ricity.state.mn.us
Homeowner
Date Rough-In Inspection Required?
� I�- �( c��l Homeowner Must Schedule All Rc
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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Owner Mailing Address - Street
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Owner E-mail Address
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REC'D A U G 21 2007
ues Electrical Ins ection
Yes Inspeati�n Other Than Rough-In:
Ins ections Homeowner Must Schedule All Final Ins
Ciry/Township County
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Projed Description
1'� c.�o � � w r. 5�c. � ��
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c�y
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ons �Will Schedule
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;ate Zip Code
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By signing this document, I certify that I am the owner as defined by Minn. Stat § 326.01 and wiil legally perform the electrical work
New Home or Associated Structure
New Home ServicelPower Supply D— 400 ampere �$35
New Home Service/Power Suppy 401 — 800 ampere �$60
New Home FeederslCircuits
Fee Ca{culation
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 80ti ampere �$60
New Feeders/Circuits — Up to 15 FeederslCircuits
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in add'Rion to New Feeders/Circuits — Mo[e 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
Detached Garage or Other Associated Structure
New Service/Power Suppiy 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (Specify)
( ) Feeders/Circuits _ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New FeederslCircuits
Reconneded Feeders/Circuits
Other (Specify)
( ) @ $6 Each
( ) @ $2 Each
Total (the fee calculated above or $35 multiplied Totdl (the fee calculated above or $35 multiptied
, by the number of required inspection trips, , by the number of required inspection trips, ,��
whichever is greater) whichever is greater)
• Requests for Electrical Inspection (REI) with a fee of S250 or less expire 12 months from the filing date. The owner must have the work completed within the
12 month period or submK another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REI to another.
A service char e of S30 wlll be added for all dishonored checks.
I hereby certify that I inspected the el�trical installation he2in on the dates stated: For Department Use Only
Rough - In Inspection(s) Date
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Final Inspection Date
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This material can be made availa6le in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.
REI 01 (6/07)