P - 76961Minnesota Depa nt of Labor and Industry
443 Lafayette d North
St. Paul, MN 155-4342
Phone: (6 84-5064
TTY/MR 51) 297-4198
www.e 'city.state.mn.us
Homeowner
Date Rough-In Inspection Required?
�' ' d Homeowner Must Schedule All Ro
Address of Inspection — Street
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Owner Na�i �I���� ,
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Owner Telephone Number(s) — Include Area Code(s)
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Owner Mailing Address — SVeet
uest for Electrical
Yes Inspection Othei
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REC'D A U G- 6 200T .
pection
Rough-In: ❑ Ready Now
Must Schedule Ail Final Insuections ��II Schedule' ,
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By signing this docume , I certify that I a the owner as defined by Minn. Stai § 326.01 and will legally perform the eledrical work
Owner Signature
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Fee Ca{culation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home ServicelPower Suppty 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Home ServicelPower Supply 401 — 800 ampere @$60 New Service/Power Supply 401 — 800 ampere @$60
New Home FeederslCircuits New Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 FeederslCircuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addition to New FeederslCircuits — More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each Feeders/Circuits U to 200 A $6 Each
Other (Specify) Reconneded Feeders/Circuits
Detached Garage or Other Associated Structure
New Service/Power 5upply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ S6 Each
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Suppty 0— 400 ampere @$35
New FeederslCircuits
Reconnected Feeders/Circuits
Other (Saecify)
( ) @ $6 Each
( ) @ $2 Each .�p�. �i�
rv
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Totdl (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 muftiplied ��
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 $250 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 inspecUon fee for the uncompleted work. Inspection fees do �ot carry over from one REI to another. _
A servfce char e of $30 will be added for aIl dishonored checks. �
I hereby certify that I inspe�ted the electriql installation he2in on the dates stated: For Department Use Only
Rough — In Inspectio Date
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Final
This material can bi
TDD (651) 297-4198.
REI 01 (6/07)
n different forms,
�, Date
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uch as large print, Breille or on a
To request, call
Voice or