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P - 75568Minnes�ta Depa ent of Labor and Industry ,443 Lafayette R d North St. Paul, MN 5 55-4342 Phone: (651) 4-5064 TTY/MRS: (6 ) 297-4188 www.electrici tate.mn.us �Co tractor Re uest for Electrical Ins Da �� Rough-In Inspection Required? Cont�actor Must Schedule All Rouqh-In of frlspectio� - Street �� '� � � - Owner Telephone Number(s) - Includ `7C�� r � l �-1 C actor Name o � � z��.e�-cG Con ractor Tel hone Number �1��o � New Home or Associated Structure tion — One Famil Dwellin /Associa Yes Single Inspection Other Than Rough-In: rctions Contractor Must Schedule All Final Ins ction Ci4v/Tnwnshin _� Cnuniv Project Mailing � � 7� Fee Calculation New Dwelling Service/Power Supply 0— 400 ampere @$35 New Dwelling Service/Power Supply 401 — 800 ampere @$60 New Dwelling Feeders/Circuits Up to 30 Feeders/Circuits - $100 New Home — More than 30 Feeders/Circuits (in addition to above) ( ) Feeders/Circuits Up To 200 A $6 Each Other (Specifvl Detached Garage or Other Associated Structure New Service/Power Supply 0— 400 ampere @$35 New FeedersiCircuits ( ) @ $6 Each �� .�lC o � �� Job/Project �ct Pe� Ready Now Will Schedule ,�.� y � Existing Home/Structure Remodel or Addition New Service/Power Supply New Service/Power Supply ccuoi �i�.n wus — Feeders/Circuits 0 - 400 ampere @ $35 401 — 800 ampere @ $60 — Up to 15 Feeders/Circuits 6 Each or 16 to 30 Ca� $100 30 Feeders/Ci A @ $6 Each _ ( ) Feeders/Circuits $2 Each � Detached Garage or Other Associated Structure New Senrice/Power Supply 0— 400 ampere @$35 New/Extended FeedersiCircuits ( ) @ $6 EacM Reconnected Feeders/Circuits ( ) @ $2 Each Other (Soecifi�l � TOtal (the fee calculated above or $35 multiplied Totel (the fee calculated above or $35 multiplied � J� by the num6er of required inspeEtion trips, by the number of required inspection trips, � whichever is greater) whichever is greater) Requests for Electrical Inspec8on (REI) with a fee of $250 or less expire 12 months from the filing date. The contractor must have the work completed within the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inapection fees do not carry over from one REI to another. �� a�� A service charge of $30 will be added for atl dishonored checks. I hereby certify that I inspected the electrical installation herein on the dates stated: For Depattment Use Only Rough - In Inspection(s) Date This materi�-c�n be made TDD (651) 287-4198. REI 02 (8/07) aoo� - � s3� Date r'oo �-� REC'D APR 2�$ 200� such as large pMnt, ille or on a tape. To request, call 1-80i or by the num6er of required inspextion trips, by the number of required inspection trips, whichever is greater) whichever is greater) � Requests for Electrical inspection (REI) with a fee of $250 or less expire 12 months from the flling date. The contractor must have the work completed withi� the 12 month period or submit another REI that includes the inspecUon fee for the uncompleted work. Inapection fees do not carry over from one REI to another JV N— L j_� �-� � A service charge of $30 will be ad d for all dishonored checks. I hereby certify that I inspected the electrical installation herein on the dates stated: For Department Use Only Rough - In Inspection(s) Date � -� �� <�= This material ca�made avallable in different forms, such as lar TDD (651) 297-4188. REI 02 (8/07) aoc� -- ov�� REC'D A PR 2� 2008 Braille or on a tape. To request, call 1-800-3 or