P - 75181Minnesota rtment of Labor and Industry
443 Laia Raad North
St Paul, M 55155-4342
Phone: ( ) 284-506�4
TTY/MRS (6S1) 297�198
�ete � I Rough-In In�pec�ton Required?
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Owner Telsphane Idumber(s) — Include Area Code(s)
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Cor�rac�or Name Contrador Mai
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Contrador Tetephone Number CoMradar E-n
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Contrador Autharized ignature Contrador Licen�s
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. � Fee Calculation
Wew Home orAssociated Structure Existing Home/Structu�+e Remodel orAdditlon
New Dwrelling Servic�e/Power Supply 0— 400 ampere �$35 Neroa SenrfcdPower Supply 0— 400 ampere @$35
Newr Dweiling Service�Power Supply 401— Sa0 ampere �$60 New Servtce/Power Suppty 401— 800 am�re (� �BO
w�..... rw....m.... C��e.�7►�ir.w�— - avrFa,�riarc/f'im��iha � 1 in fn 15 Faioeinrd�_ire!adfc
New Home —
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D�ached tierage or Other Assoclat�! Structure
Idew Sero[ce/Po�r Suppiy 0— 400 ampere �$35
New FeedersJCircuits ( ) C� $6 Each
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Detached Garage or Othet Assoclated Structure
Ne�ro SeririoefPower Supply 0— 40D ampere (� $35
New FeederslCUcu� ( ) Ca� � Each
R�nnected FeederaJCircuits ( % � ) @ $2 Each �Q. � U
Other (Sp�r) - Other (Specify) Sv.¢ cas��/'6� a s�
Total (the fee calculated above or $35 multiplied TOtdl (the fea calculated above or $35 muttipG�i
by the numbe� ot requir� inspedian trips, by the number of required ins�c�on trips, ��: �o
whid�ever is greater) whichever fs greater)
Requ�ts tor El�tricel U�spectlon (R� t�rith a t� af ffiSO or less expire 12 monfhs Trom the fl!&�g de�. The ea�or m�t heve the wwk eompleted �ithin
the 12 mornh periai or submlt another 1�1 thet d�clud� the tns�ctlan f� tor the �mcomP�eted worh. ln.vpecdon t� do not earr�I aver imm one REI to
anottler.
A eervlce eharge of 530 wlll � added for ap olshonQr� che�ke.
TDD (861) 257-41�.
REI 02 (6/0�