P - 76896Minnesota Depa ent of Labor and Industry
443 Lafayette d North
St. Paul, MN 155-4342
Phone: (6 284-5064
TTY/MR 651) 297-4198 �
www.el ricity.state.mn.us
Contractor/Re istered Em
Dat Rough-In Inspection Required?
CJ�/ Contractor/Employer Must Scheduie Ail Rouah-In
Adjlress/of Inspection —
Owner Name
Owner Telephone Numt
�a
�
0
r
0
REC'D AUG 2'3 2001
��'6 ��� /��f
est for Electrical Inspection
Inspechon Other Than Rough-In: � Ready Now
ctoNEmployer Must Schedule A�I Final Inspections Will Schedule
mship County
— Include Area Code(s) �I ����y�� � ���
�
�er Name Contractor/Registered Employer Mailing Address
�� _
loyer Telephoi Numb �
,a��
loy�,r.l�nthorized Signatu
Contractor/Employer E-mau Hu�ress
ontact Person
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Fee Calculation
Service/Power Supply 0'— 400 ampere @$35 � Technology System Devices ( )@ 75¢ Each
Service/Power Supply 401 — 800 ampere @$60 Separate Bonding Inspections for SwimmingPools and
E ui otential Planes $35 Each
Service/Power Supply Above 800 ampere @$100 Center Pivot Irrigation Booms ( )@$35 Each
Plus Electrical Drive Units $5 Each
FeederslCircuits Up Ta294 A { }� $� Eaekr �urrjinaire fcetrofrt iUlodificaflons ( ) n� 25¢ Each
Feeders/Circuits Above Z00 A ( )@$15 Each Concrete-Encased Electrode Inspection ( )@$35 Each
Investigative Fee $70 Or The Total Inspedion Fee,
Reconnected Feeders/Circuits ( ) @ $2 Each
Whichever Is Greater U To $1,000
Manufactured Home Park Lot Su i Special Inspection Fee ( ) Hours @$80 Per Hour
PP Y ( ) @ $35 Each
Plus Miles The IRS Milea e Rate of
Recreational Vehicle Site Supply Equipment Other
� � �;.....:.., r,_:_:__.:__ :_ «_ � . • — -- — • -
Street, Parking Lot, Lighting 5tandard ( )@$5 Each OV2� BOO VOItS — Add the combined seMce/prnyer supply and feededarculttee ta
- result in doubla the-regular fee (does rrot aopN.to electrie ygn and outline IiphNng)�
Transformers Up to 10 kva � ( )@$15 Each � ) New Multi-Famity Dwellings @$70 Each
With Up To 20 Feeders/Circuits
Transformers Over 10 kva ( )@$30 Each ( ) Additional Circuits Above The 20 Allowed Per Unit
$6 Each
Electric Signs and Outiine Lighting Total (the fee calculated above or $35 multiplied
Transformers/Power Su lies $5 Each by the number of required inspection trips, '
whichever is greater)
Requests for Electrical Inspection (REI) with a fee of 3Z50 or less expire 12 months from the filing date. The contractor/employer 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
�7'ut �//� ,�- from one REI to another.
�� �% A servic char e of 530 wlll be added for all dishonored cliecks.
I hereby certify that I inspected the electrical installati n herein o the dates stated: Fo� Department Use Only
R o u g h — I n e c t i o ( s) f-� �' a 1 µ� Da te
/�" �^22,.�%
Finallns ionp �„ ,, Date
i ms mpteriai can ne maqe available in different fo�ms, su�ii as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.
REI 03 (6/07) �