P - 76952Minnesota Department of Labor and Industry
443 Lafayette Road North
St. Paul, MN 5155-4342
Phone: (65 284-5064
TTY/MRS' 651) 297-4198
www.ele 'citv.state.mn.us
Corl�iractor Re uest for Electrical I
Date Rough-In I�spection Required?
�� :"�' � Contractor Must Schedule All Rou I
,
Address of Inspection - Street
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Oy�ner Name . ,
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Owner Telephone Number(s) - Include Area Code(s)
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Yes
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REC'D J U L 12 2007
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Dwellin /Associated Structure
i Other Than Rough-In: Ready Now
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Schedule All Final Ins ections Will Schedule
Ciry/Township County •
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Project Description =
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Contractor Telephone Number Contractor E-mail Address Electrical Utility
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itractor License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0- 400 ampere @$35
New Dwelling ServicelPower Supply 401 - 800 ampere Q$60
to
New Home - More
reaersn.�rcuiw - �
:s (in additio� to
200 A C� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere (a� $35
New Feeders/Circuits ( ) Q $6 Each
Job/Project Contact Person
Deb
Existing Home/Structure Remodel or Addition
New Service/Power Supply
New Service/Power Supply
Feeders/Circuits
0 - 400 ampere Qa $35
401 - 800 ampere @ $60
�s - Up to 15 FeederslCircuks
$6 Each or 16 to 30 Q$100
- More Than 30 Feeders/Circui
ts Uo to 200 A Cd2 $6 Each
( ) Feeders/Circuits � $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New/Extended Feeders/Circuits ( ) Q $6 Each
Reconnected FeederslCircuits ( ) � 32 Each
TOtel (the fee calculated above or $35 multiplied TOtel (the fee calculeted above or $35 multipUed
by the number of required inspection trips, by the number of requtred i�spectbn trips, � Gi �� L1
whichever is greater) whichever is greater)
Raqwsts for Elecbical Inspoctlon (REI) with a fee of 5250 or less expire 12 moMhs from the NUng date. The eontraetor muat haw the work eomplebd wkhin
the 12 month poriod or submk anothar REI that Includes tha Inspaction fae for the uncompleted work. Inspeetion faas do not carry owr irom one REI to
another.
A service eharge of i30 will ba added for all dishonored checks.
I hereby certify that 1 inspected the electrical installation herein o� the dates stated: For Departmant Uss Only
Rough - In Inspection(s) Date '
Final
This materi�i ca�1 be
TDD (651) 297-4198.
RE102 (6/07)
�
�: Date
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le in differer�t forms, such as la print, Brailie or on a
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or