P - 75287Minnesota Depa •' nt of Labor and Industry
443 Lafayette R d North
St Paui, MN 55-4342
Phone: (651 84-5064
TfY/AIfRS: 1) 297-4198
vv�wu�r.el ity.state.mn.us
Contractor Re uest for Electrical Ins
� �3 ^ � Rough-In Inspection Required?
Contractor Must Schedule All Rou h-In I
Address of inspec�ion — Street
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Owner Name�j
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Owmer Tefephone Number(s) — Include Area Code(s}
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RESIDENTIAL ELECTRICAL PERMIT BY CONTRA.CTOR
PERMIT # — � ��
RECENED: 0
tion — One Famil Dwellin /Associated Struciure
y� Single Inspecti�n Other Than Rough-In: � Ready Now
:cii�ns Confractor Must Schedule All Final Ins ctions ❑ Will Schedule
CitylTownship County
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Projed Description /1
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ictor E-mail Address
Fee Calculation
New Home or Assaciated Structure
Plew DwelGng Senri�/Pouver Suppy 0— 400 ampere @$35
New Daveiling ServiceJPower Supply 401 — BDO ampere @$6D
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Person
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Existing Home/Structur� Remodel or Addiiion
� � I New 5ervicelPower Supply
New Senrice/Power Supply
New Feeders/CiFCUits — Up to 15
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Plew Home — More than 30 �eeders/Cira�its fin addition to New
Other
Detached Garage or Other Associated Structure
New Service/Powrer Supply
New FeederslCircuits
Other (Spec+fy)
0 — 4U0 ampere � $35
( ) @ $6 Each
0 — 400 ampere @ $35
401— 8D0 ampere @ $60
achor16to30�$100
30 FeedersJCircuits
to 200 A (a� $6 Each
( ) Feeders/Circuits � $2 Each I
Detached Garage or Other Associated Structure
hiew Senrice/Power Suppty D— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Re�nnested F�ders/Circuits ( ) � $2 Each
To�'dl (the fee calculated above or $35 multipl'ied Total (the fee cala�lated above or $35 rnulttptied 3��
by the number of required inspecUon trips, by the number of required inspedion trips,
vahichever is greater) whichever is greater)
Requests for Electrical lnspection (REI) with a%e of $250 or less expire 12 morrths from the flling date. The contractor must have the work completed within
the 12 month period or submk anofher REI that includes the inspecNon fee for the uncompleted work Inspection fees do not carry over from one REI to
anofher.
A service charge of $30 will be added for all dishonored checks.
I hereby certiy that I inspeded the el�trical �stallation herein on the dates staterl: For Department Use Only
Rough — In Inspection(s) Date ��p �qR � 4 200� � �
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Fir�al Inspection Date
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This material ca e m ailable in different fom�s, such as large print, Braflle or on a tape. To
TDD (651) 297�188.
RE102 (6/07)
Yoice or