P - 75502�
Minnesata De
443 Lafayette
St. Faul, MN
Phone: (651)
of Labor and Industry
TlY/MRS: ( ) 297-4198
www.e►ectn .state.rnn.us
Con ctor Reguest for Electrical I
Da� ,�� � Rough-In Inspect�on Reqwred�
Contracior Must Schedute All Rou I
Address af Inspect►an - Street �
phr�one Numb��1� `
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Teleohone Nurnber _ _
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Signature �
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Code(s)
tion — One Fami�Y Dwellin /Associated Structure
Yes �S�ngle Inspection Other Than Raugh-In: Ready Nrnv
�ctions � Contractor Must Schedule All Final Inspections ❑ Will Schedule
l.�ryr i srn � � � ......,,
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Pro�ect Descnption �n�,, �y
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Contrac:or E-mad Address
;ontr�tor License Number
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Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power 5upply o- 400 ampere,@ S35 + i`~— _
New Dwelling Service/Power Supply 401 - 800 ampere @ 360
Up to 30 Feeders/Circwts - s�'
New Home -�llore than 30 Feeders/Circuits (in addiGan to
abo �e) I 1 Feeder�/Circurts Up To 200 A(� SS Each �
Other (Specify)
Detached Garage or Otfier Associated Structure
New Service/Pawer Supply
IVew Feeders/Circuds
Other (Specafy)
0 - 400 ampere (c� $35
� )@S6Each
�t��,t,,
0
Existing=�Home/Structure Remodet o� Additian
New Service�Power Supply 0-400 ampere iv 535 �
! �ja�
New Serv�celPower Supply 401 - 800 ampere @�
NeuWExtended Feeders/Circwb - Up to 15�e�ed�� Circwb.
200
Reconnected
Detached Garage or Other Associated SWcture
Nea� Service/Power Supply 0- 4Q0 ampere aQ 535
New/Extended FeederslGircuds ( ) � S8 Each
Reconnected FeederslCircwts ' ( ) (� $2 Each
�
_�
_ ... �.- -----•—• • ---•—_ _— Other(SPecrfY? � ° `°
Other (SpeGiy) • • � d
TOtal (the fee calculated above ar $35 muldplied I Total (the fee calcutated above or $35 multiplied
by the number of reqwred �nspecUOn tnps, by the number of reqwred mspection tnps, ��
wnichever is greater)
wnichever �s greater)
Requests for Electncal Inspection (REI) with a fee of SZ80 or less expire 12 months from the filing date. The contractor must heve the work ccmP�ed �in
the 12 month penod ar submit another REf that ineludes the inspection fee for the uncompleted work. Inspection feea do not earry over from one REI to
another.
A service charge of SSO vwll be added for all dishonored checks. --
— ��iL�CJ��nW� �Ir
I hereby cendY that I �nspectea lne eiecmcai �nstauauon nereui an the datea statea ,
Rough - In Inspect�on(s) Date i
Final InsP�ion -` -- ---. —.----•- pa--te , I�LV U ��� � � 20�8
_ '��-�S � ! __� voj e
" "` � To request, ca�l 1-800-342•5354 (DWL-DU)
Thfs material can be made availabie in different forms, such as la p� t, Breille or on a tape.
TDO j851) 297-4198.
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