P - 75715Minnesota Departrrient of Labor and industry
443 Lafayette ROad North
Sti Paul, MN 155-4342
Phone: (651 � 84-5064
T7YIMRS: 51) 297-4196
vvwvr.ele city.state.mn.us
Homeowner
Date Rough-In Inspection Required?
7' "� Homeowmer Must Schedule All Rc
Address of Ins�on — Street
Name
Ovmer Teleph�ne Number(s) — inc��
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Owmer Mailing Address — Street
�� �. Ql� No �r�r� A
Owmer E-mail Address
� I � �Q �, ,- 8�a' � Z�-�` - �la-1 -
that I am the owner as defined by Minn. Stat § 326.01 and wrill legaliy pertorm the elec�rical work
By signing this doc�ment, I
v
codecs>
uest for Electrical
� y� Inspection Ofher
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REC'D J U L 3 0 2007
Ready Ncvw
lfdill Schedule
C' /Township County
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Project Description
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Electrical
State Zip Code
(�lls� ��+21
�
New Home or Associated Structure
New Fioma Senrics/Power Supply D— 400 ampere �$35
- IVevr Home SenriceiPower �up�ly 407 = 800 �mpere @$60
New Home FeedersfCfrcuits
Up to 30 Feeders/Circuits -
— More than 30 Feeders/Circuits (in add�ion to
To 200 A
0
Fee Caiculation
Existing Home/Structure Remodel or Additlon
New Sen+ice/Podver Supply 0— 400 ampere $35
New Seroic�lPower SuPPIy 401 — 800 ampere @�60
New Feeders/Circuits — Up to 15 Feeders/Circuits
100 FeedersJCircuits $6 Eadi or 16 to 30 $100
�Alcw Fcariprc/t_irrH�iFs _ Allnrra Than 3n F�lerc/f:irr_uits
Detached Garage or Other Associated Structure
200 A (o� $6 Each
( ) FeedersJCircuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New FeedersJCircui� ( ) @ $6 Each New Feeders/Circuits ( ) � $6 Eac�
Other (Specify) '
Reeonneded Feeders/Circuits ( ) @ $2 Each
Other (Speciy) Other (SPecifY) � Givfi L ��GC�I .�
Totai (the fee caldilated above or $35 mu(tiplied Total (the fee calculated above or $35 multiplied �� �
by the number of requifed inspection trips, by the number of required inspection trips,
whichever is greater) � whichever is greater)
Requests for Electrieal Inspection (RE1) with a fee of $250 or less ezpire 12 morrths from the filing date. The owner must have the work completed writhin the
12 mor�th period or submlt another f2El that indudes the itffipectlon fee for the uncompieted work. InspetUon fee.s do not carry over from one REI to another.
A service ch e of $30 vvlli be added for all dishonored checks.
i hereby ceNfy that I inspeded the electricai installation herefi on the dates stat�: For Department Use Only
Rough — In Inspection(s) Date
Final
This material ean�
TDD (651) 297-4196.
REI 01 (6/07)
� � te I
--�._ -� .--� 7
in different forms, such as large print, Brallle or on a
(DIAL-DLI) Yofce or