P - 76685�
Minnesota Departme of Labor and Industry
St.3Pau�ayMNeS oa Orth �C��� —C,'�� I �
PT1Y/MRS 51> ) 297�198 �� v N�� � 2007
www.eled ' .state.mn.us
Con ctor Re uest for Electrical Ins ection — One !.�.
Da ��� Rough-In Inspection Required? Yes Single Inspe
� Contrador Must Schedule AII Rou h-In Ins edions Contractor �
Arl rac.a nf Incniariinn — Strt�t ,a� C:itv/Tnwnchin
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�umber(s) — indude Area Code(s)
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Project Description '
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j Fee Calculation
New Horne or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0— 400 ampere @ S35 New Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Dwelling Feeders/Circuits New �eeders/Circuits — Up to 15 Feeders/Circuifs
— More than 30
iu=�
i to
Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
— More Than
A
00
( ) Feeders/Circuits $2 Each I
Detached Garege or Other Associated Structure
New Service/Power Supply 0— 400 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
Reconnected Feede`s/Circuits ( ) @ $2 Each
Other (Specifv)
Tot81 (the fee calculated above or $35 multiplied TOt81(the fee calculated above or $35 multiplied ,
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) wlth a fee of 5250 or less expire 12 mo�ths from the flling date. The contractor must have the worlc completed within
the 12 mordh period or submk another REI that includes the Inspecdon fee for the uncompleted work. lnspecdon fees do not carry over from one REI to
another.
A service charge of S30 will be added for all dishonored checks.
I hereby cerlify that I inspec:ted the elect�ql Installation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) Date
Inspection
rnis matenal can 6e made
TDD (6S1) Z97-4198.
REI 02 (6/07)
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as large print, Breflle or on a
ro request,
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