P - 76882Minnesota De nt of Labor and Industry
443 Lafayett oad North
St. Paul, 55155-4342
Phone: 1) 284-5064
TTY/M : (651)297-4198
www. ciricitv.state.mn.us
� Homeowner
Date ough-In Inspection Required?
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• " � Homeowner Must Schedule All Rc
Address of Inspection - treet
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Owner Tele on Number(s) - Include Area Code(s;
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REC� � u � 2 s 2007
uest for Electrical Ins ection
Yes Inspecti�n Other Than Rough-In: ❑ Re�eJy Now.
�ns ctions Homeowner Must Schedule All Final Ins ctions VVill Schedule
City/To ship � Count `
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i document, 1 certify that I am the ovmer as defined by Minn.
New Home or Associated Structure
New Home Service/Power Supply 0— 400 ampere @$35
§ 326.01 and will legally pertorm the electrical work
Fee Calculation
New Home ServicelPower Suppty 401 — 800 ampere �$60
New Home Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home — More than 30 Feeders/Circuits (in adddion to
A (rD $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New FeederslCircuits ( ) @ $6 Each
Existing Home/Structure Remodel or Addition
New Service/Power Supply (p(t.�G J 0— 400 ampere @$35
New 5ervice/Power Suppiy 401 — 8DD ampere �$60
N e Circuits — Up to 15 Feeders/Circuits
� eeders/Circuits $6 Each or 16 to 30 $100
ers/Circuits — More Than 30 Feeders/Circuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structur�
New Service/Power Suppty 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Reconneded Feeders/Circuits ( ) @ $2 Each
Other (Specify) _ �
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Total (the fee calculated above or $35 multiplied Tot1) (the fee calculated above or $35 muftiplied �
by the number of required inspection trips, by the number of required inspection trips, Q� ��
whichever is greater) whichever is greater) (� ��
Requests for Electricel Inspection (REI) with a fee of 5250 or less expire 12 months from the fifing date. The owner must have the work completed within the
12 month perfod or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to another.
A service cha e of S30 wfll be added for all dishonored checks.
I hereby certify that 1' spected the electriral installation herein on the dates stated: i I For Department Use Only
Rough - I p ction(s /Y/?�!��' I �f al Date `�'� ��
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Final atio 7
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This aterial an be made available in different forms, such as targe'Qrint, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.
REI 01 (6/07)