P - 76803Minnesota Depah
443 Lafayette Ra
St. Paul, MN 551
Phone: (651) 28
TTY/MRS: (651
www.electric�ty.
Contrac
Date
D ��
Ad ess of Inspe
Owner
of Labor and Industry
��� _ ����y
REC'D . F C 12 2001
97-4198
ate. m n. us
r Re uest for Electrical Ins ection — One Famil Dwellin /Associat d Structure
Rough-In Inspection Required? ❑ Yes Single Inspection Other Than Rough-In: eady Now
Contractor Must Schedule All Rou h-In Ins ections Contractor Must Schedule All Final Ins ections ❑ Will Schedule
c�ion — Street �., � � ^ �. City/Tow�ship , _ County �
Owner Telephone Number(s) — Include Area
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C ctor Name � ' - — � Contractor Mailing Add{ess �� � ���
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Con�ct� r�ele h ne Numbe�� Contractor E-mail Address Electrical Utility
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Contractor Aut ' ed �Signature Contractor License Number Job/Project Contact Person
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Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0– 400 ampere @$35
New Dwelling Service/Power Supply 401 – 800 ampere @$60
New Dwellina Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home – More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Uo To 200 A(cil $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35
New Feeders/Circuits
Other (Specify)
er
( ) @ $6 Each
New Service/Power Supply 0– 400 ampere @$35
New Service/Power Supply 401 – 800 ampere @$60
New xtended Feeders/Circuits – Up to 15 Feeders/Circuits
�. Feeders/Circuits $6 Each or 16 to 30 $100 /
New/Extended Feeders/Circuits – More Than 30 Feeders/Circuits
) Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
/ v
Tota) (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied
by the num6er 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 a250 or less expire 12 months from the filing date. The contractor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates stated: For Department Use Only
Rough – In Inspection(s) Date
Ffnallnspectlon --° -? Date
, ,-
C__..�_.. �=. � ..Y . /— //— G�,`
This material can be made available in different forms, such as large print, Braille or on a tape. To request, ca
TDD (651) 297-4198.
REI 02 (6/07)
) Voice or