P - 75561Minneso4a Departrry of Labor and Industry �
443 Lafayette R " North �
St Paul, MN 55-4342
Phone: (65 84-5064
TTY/MRS: 51) 297-4198
www.elec city.state, .us
Contra r� uest for Electrical Ins e
Date , Rough-In inspection Required?
��� Contractor Must Schedule All Rouqh-In Ins
dress of In�ctio� �ree� A� I r ��O'//^ �_�'
l I �I .L.P,v v � � I �l
ction – One-
Yes Single I
�wner Name Pro,
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Owner Telephone Number(s) -- Inclu�e Area Code(s) �
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__ _ _ __i;nr,tr,�tor Nam� ,,�. �¢�o(��tor Mailing Address
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Contractor Telephone
C;�ntractor A hor' d
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ami�y- we Iing/Associated
spection Other Than Rough-In: (�
dule
�tructure
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�c��'/.��� pvjlV "��ctor E-mail Address Electrical Utility
7�3-53a�-20 fl
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���P ; Contract Lic nse Number �.Job%Project Contact Person
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Fee Calculation
New Home or Associated Structure
_. _._ . _.__,. . __ .�..ti .____.__ __._..__.-----_ .._---_.. _.._. _.._�.
New pweuing Service/Power Supply 0- 400 ampere @ T�3S �
-•---- -_._�_ ._.�.__....�____._____-_----._._.__.� _�.
New Dwelling Service/Power Suppty 401 - B00 ampere @$60 �
-- ------ --_------ - - -- ---------�--
New Dwelling Feeders/Circuits �
Existing Home/Structure Remodel or Addition
_.. __...._ . _. _... _ _... .
- ---.._...__..---- --...__.....�._.
. _ ._ _,. .
New Service/Power Supply 0- 40U ampere @$35 �
--- - •-- ----- ------. __- ---- --..._ .-- ----------
U�to 30 F�eeders/C�rcuits_$1D0�_
New Honie - More than 30 Feeders/Circuits (in addition to
___���_�ve�`�__LFeeders/Circuits U To 200 A(a� $6 Each
-)ther (Sp�.r,ify) -- - -
- -- - - --I_ _ ._.
Detached Garage or Other Associated Structure
��Jew Service/Power Supply 0— 4QD ampere ra $35
rdr"v FeederslCircuits ( � ,on�, $6 Each
7ther (Specify) �.-___.._. �.. _.___.. ._
_ _ .. __.___ .._.__ _._ �- --.-
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O;he� (Specify)
Tot81 (the fee calculated above or $35 multiplied
l,y the number of required inspection trips,
whichever is greater)
New Service/Powe, Supply 40� - 800 ampere @�60
NewlExtended FEeders/Circuits - Up to 15 Feeders/Circuitc —1
reeders/Circwts a� $6 Each or 16 to 30 $100 �_
L..- - -- � -- �--- @
New/Extended Feeders/c:ircuits - More Than 30 Feeders/CirCUits
( ) Feeders/Circuits U�to 200 A (�D $6 Each __ _ � _ _
Reconnected Feeders/Circuits
_ ____ `_ ___ _. _ _�__ __� Feeders/Circuits (�a, $2 Each �
Detached Garage or Other Associated Structure
New Serv�ce/Power Supply
NewiFxtended F eeders/Circwts
ReconnPCted FeederslCi:cuits
_.___._ .__�_._ � _ . .---....�._. _ ... _._.
OthEr (Specify)
--- .�...
D - a00 ampere @ $35
. ��_-- _
( ;@$6Ea�h �
_._... _ ,_..._.�..__.. � _ .__ _..�
1 1 @ $2 Each j
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____. ----�_�_.._
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Tot21 ithe fee caiculated above or $35 multiplied ' r-
by the number of requ�red �nspection tnps, ;� ���
whichever is greater)
_.___.�__._ ..�._ _._._. l,.r.L __ ._ ..
Requests for Electrical InspecGon (REI) with a fee of $250 or less expire 12 months From the filing date. The contractor must have Ehe work completed wrth
the 12 month period or submit another REI that includes the inspeetion fee for the uncompleted work. Inspection fees do not carry over from one REI t�
_ _ another.
A service charge of S3Q wilt�e added for all dishanored checks.
_. _..__._...f__."__._"""'_.____— �_�.....r. _�_�..._..T.'_'...____'___."...._. _ __.._
! hereby certify that I inspected the electrical installation herein on the dates stated i or Department Use Only
Rou,yh - In Inspection(s) Date i f.p �A � I f���
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_._ .�_ .. ---- _.._..__.___--- -- _.-_-----.— ___.__ ..1 .
rinal Insper.ti�n Date , SEP 0 4 2008
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This material can be made availabfe in different forms, such as large print, Braille or on a tape. 7o request, call 1-800-342-5354 (OIAL-DLI) Vo�c�