P - 76232Minnesota Department of Labor and Industry
443 Lafayette Road North
St Paul, MN 55155-434
Phone: (651)284-5
TTY/MRS: (651)2 198
wv�nr. electricity. .mn. us
Contract r Re uest for Electrical I
Date Rough-In Inspection Required?
�'' zO " C� % Contraotor Must Schedule All Rou I
Address of Inspedion - Street
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Corrtiactor Name
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Contractor Teleph
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REC'D JUL 2�0 2001
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tion — One Famil Dwellin /Associated Structure
y� Single Inspection Other Than Rough-In: Ready Now
�ctions Contractor Must Schedule All Final Ins 'ons ❑ Will Schedule
City/Township Coun
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Projed Description
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ng Address
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Number Contractor E-mail Address Electrical Utility
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Signaiure Contrador License Number Job/Project Contact Person
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Fee Calculation
Nevv Home or Associated Structure Existing Home/Structure Remodel or Additlon
New Dwelfing Service/Power Supply 0- 400 am�re @$35 Plew Service/Power Supply D- 400 ampere @$35 ��" m�
�
New Dwelling Senrice/Power Supply 401 - 800 ampere �$60 New Service/Power Supply 401- 800 ampere @$60
- More,
- New Feeders/Cifcufts - Up %15 FeedersJCircuits
to 30 Feeders/C'rcc�its -$100 FeedersJCircwfts $6 Each or 16 to 30 $100
s/Circx�fts (in addition to New Feeders/Circuits - More Than 30 Feeders/Circuits
; lJo To 200 A la� $6 Each ( ) Feeders/CircUits U to 200 A $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0- 4QD ampere �$35
New Feeders/Circuits ( ) � $6 Each
iSPe�Y)
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New Senrice/Power Supply 0- 400 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
Reconneded FeederslCirouits ( ) @ $2 Each
Other (Specify) �
Total (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied Q �
by the number of required inspectio� trips, by the number of required inspection trips, �s
whichever is greater) whichever is greater)
Requests for Electrical Inspectfon (REI) wfth a fee of $250 or less exptre 12 morrths from the flling date. The cordractor must heve the work completed wlthin
the 12 month period or submk another REI that ineludes the inspection fee for the uncompieted woric. inspection fees do not carry over from one REI to
enother.
A service charge of $30 wili be added for all dfshonored cheeks.
I hereby certify that I inspeded the electrical fistallation herein on the dates stated: For Department Use Onty
Rough - in Inspection(s) Date
Inspection
Tfiis material can be
TDD (657j 297-0�198.
REI 02 (6107)
uaie
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fortns, such as large �
or on a tape.
or