P - 75435Minnesota Departmetr(4 of Labor and Industry
443 Lafayette Roa�`North
St. Paul, MN 5, 5-4342
Phone: (651, � 4-5064
TTYJMRS� 51) 297-4198
www.el city.state.mn.us
C ractor Re uest for Electrical Ins
Da e Rough-In Inspection Required?
� Contractor Must Schedule All Rou h-In
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O ner Name
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wner Telephone Num¢er(s) _ clude Ar�ode(s)
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ctor Name •
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actor orized Signature
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REC� OCT - 3 2001
:tion — One Famil / Dwellin /Assa
Yes Single Inspection Other Than Rough-In:
:ctions Contractor Must Schedule All Final Ins�
Ciry/Townshp Counry
Project Descriptio�
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Address
Contractor License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60
New Dwelling Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home — More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A $6 Each
Other (S�ecifv)
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
Natv Feeders/Circuits ( ) @ $6 Each
Other (Soecifvl
�`
ctrical Utility
;tructure
Ready Now
Will Schedule
Existing Flome/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
(� ) Feeders/Circuits @$6 Each or 16 to 30 $100
New/Extended Feeders/Circuits — More Than 30 Feeders/Circui
( ) Feeders/Circuits Up 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
NewlExtended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Saecifvl
Total (the fee calculated above or $35 multiplied TOtal (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) ti e
Requests for Electrical Inspection (REI) with a fee of $250 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 aIl dishonored checks.
i hereby certify that I inspected the electrical instailation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) Date
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Final Inspecti/ �,�--' �� Date
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Thls material can be made available in different forms, such as large prfnt, Brallle or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Volce or
TDD (651) 297-4198.
REI 02 (6/07)