P - 75548Minnesota Ae
44� Lafayette
St. Paul, MN
Phone: (651)
TTY/MRS: (6
�
Name
;nt of Labor and Industry
North
297-4198
ate.mn.us
r Re uest for Electrical Ins
Rough-In Inspec�ion Required?
Contrador Must Schedule All Rou h-In
�ion - Street
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Idumber(s) -
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Corrtractor Name
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Con ctor Telephone Number
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#ion — One Famil Dwellin /Associated Structure
Yes Single Inspedion Other Than Rough-In: � Ready Now
:dions Contrador Must Schedule All Finai Ins ons ❑ Will Sc�edule
Cit�dTownship County
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Projed Descrip n
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idor Mailing Address
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ictor F�mail Address _ , Electrical Utility
Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0- 400 ampere @�35 New Service/Power Supply 0- 4Q0 ampere @$35
New Dwelling Service/Power Supply 401 - 800 ampere @$60 New Service/Power Supply 401 - 800 ampere @$60
New Dwelling Feeders/Circuits New/Extend� Feeders/Circuits - Up to 15 Fe�ers/Circuit�
ua��vnwns - .y
(in addition to
� A C� $6 Each
00 ( ) Feeders/Circuits @$6 Each or 16 to 30 (c� 5100
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New FeederaJCircuits ( ) @ $6 Each
Other (Speaiy)
Other
- More Than 30 Feeders/Cii
ts U� to 200 A Calf_ �6 Each
Feeders/Circuits
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Recc�nn�ded Feeders/Circ�its ( ) � $2 Each
TOt�I (the fee calculated above or $35 multipli� TOtel (the f� calculated above or $35 multipli�
by the number of required inspection trips, by the number of requir� ins�on trips, `� �
whic.�ever is greater) whichever is greater) "�
Requests for Electr�cal I�pec�on (REn with a fee of a260 or I�s explroe 12 moMhs irom tlre flting date. The cantrador must have Ure work comptetiad wffhln
the 12 month perlod or aubm(t another REI that Irtalud� the I�peeUon fee tor the wrcomple�d work. Inspe�tion fe� do not carry over from one REI to
another.
A service charge M;30 wlll be added for Ishonored checics.
1 hereby certiTy that I inspected the electrical instatladon herein on the dates stated: !� For De
Rough - In Inspecti n(s)�j Date ' {`9�� �C\�� � ONy
� A l.i A itn__ — c� /n� r r�.- �a .� v ld � e��J '
Final Inspection
This matenal can be
7DD (657) 297-4198.
Date
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able in differern forms, such as larai
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or on a tape. To
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