P - 75719Minnesota Department�f Labor and Industry
443 Lafayette Road � rth
St. Paul, MN 551 342
Phone: (651) 2 5064
TTY/MRS: (6 297-4198
ContraEtor Re uest for Electrical In
�ate Rough-In Inspection Required? ,1�
7 3�� a� ConUador Must Schedule AU Rou h-I
�ess of Insp on - Street .
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REC'D AUG — 3 2007
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tion — One Famil Dwellir
yeS Single Inspection Other Than
Contractor Must Schedule All Final Ins ection
;iry/To ship County
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�ro;ed oescriptio
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Structure
Ready Now
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Contrador E-mail Address
�ject Gon�ct Person
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� Fee Calculation
New Home or Associated Structure Extsting Home/Structure Remodel or Additton
New Dweiling Service/Power Supply 0— 400 ampere �$35 New Service/Power Supply 0— 400 ampere aLD $35
New Dwelling Service/Powar Supply 401 — 800 ampere �$60 New Servic�/Power Supply 401 — 800 ampere @$60
— More than
New Feeders/Circuits — Up to 15 FeederslCircuits
) Feeders/Ciraiits -$100 FeedersfCircufts $6 Each or 18 to 30 100
•cuits (in addition to New Feeders/Circuits — More Than 30 Feeders/Grcuib
To 200 A Cc� S6 Each Feeders/Circuits U to 200 A $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @ 335
New Feeders/Circuits ( j(� S6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits (— / u�y+ � cau�
Reconneded Feeders/Circuite ( ) aQ S2 Eech
Total (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied ��� � z, �
by the number of required inspection trips, by the number of required inspection trips, �
whichever is greater) whichever is greater) � V
Requests for Etectrleal InapecUon (REI) wlth a fee of t280 or lese ezpire 12 montha irom tha Flling date. The contraetor m�t have the work completed wfthln
the 12 month pe�iod or aubmft another REI that Includes the Inspectlon fee for the uncompleted work. Inspecdon fe� do not eerty over from one REI to
another.
A serviee charge of S30 will be added for all dlahonored chaeks.
I hereby certi(y that I inspeded the atectrical installation herein on tf� dates stated: Fof Department Use Only
Rough - In Inspection(s) Date
Final I
This mateNal aan be
TDD (661) 287-4198.
REI 02 (8/07)
' Date I
:�,— `7 ���-��
• In dNfarent torms. auch aa large print, Braille or on a tape. To request,
o�