P - 75724Minnesota De
443 Lafayette
St Paul, MN
Phone: (65
TTYIMRS•
www.el cit
of Labor and Industry
)297-4198
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REC'D AUG 2 2 2007
Con ractor Re uest for Electrical Ins ection — One Famii Dwellin /Associated Structure
Date Rough-In Inspection Required? ❑ Yes Single Inspection Other Than Rough-Iri: � Ready Now
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Address of Inspedion - Street CitylTovmship County
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Owmer Name Projed Descxiption
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Owner Telephone Number(s) - Include Area Code(s) c//L Ct�i7 �/�E�IK GIC PA�/E�L � '�s7'��L 2v ��� �ya��
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Contrador Name Contractor Mai(ing Address
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C�ntractor Telephone Number Contractor E-mail Address Electrical Utility
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Contractor Authorized Signature Contracior Li�nse Number Job/Project Contact Person
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Fee Catculation
New Home or Associated Structure Existing Home/Sttvcture Remodel or Addition ',
. Plew Dwelling Servic�/Power Supply 0– 400 ampere �$35 New Service/Power Supply �� 0– 400 ampere �$35 3�
New Dweiling Service/Pov�r Supply 401 – 800 ampere @$60 New Senrice/Power Supply 401 – 8D0 ampere �$60
Neav Dw+elling Feeders/Circuits New Feeders/Civcufts – Up to 15 Feeders/Girca�its � /
U to 30 FeederslCircuits -$100 eeders/Cira�its $6 Each or 16 to 30 $100 ��
New Home – fdlore than 30 �eeders/Circx�its (in addi�on to New FeedersJCircuits – More Than 30 FeedersJCircuits �
above FeedersJCircuits U To 200 A $6 Each FeederslCircuit5 U to 200 A $6 Each
Other (Specify) Reconnected FeederslCircuffs �-
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FeederslCircui� $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0– 400 ampere @$35 New Service/Power Supply 0– 400 ampere @$35
New FeederslCircuits ( ) � $6 Each New Feeders/Circuits ( ) @ $6 Each
Other (Specify) Reconnested Feeders/Circuits ( ) @ $2 Each
Other (SPecifY) Other (SRec�fY) �`��
Total (the fee calculated above or $35 muttipifed Total (the fee caiculated above or $35 multipiied
by the number of required inspedion trips, by the number of required inspedion trips,
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) wiU� a fee of $250 or less expire 12 montl�s from the flling date. The corrtractor must have the work completed within
the 12 month period or submft another REI that includes the Inspection fee for the uneompleted work. InspeeUon feas do not earry over from or►e REI to
another.
A servtce eharge of $30 will be added for all dishonored checks.
I hereby certity that I inspected the eleeUical installation hereM on the dates stated: For Departrnent Use Only
Rough - In Inspection(s) Date
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This terfal can be made available In different fom►s, such as large print, Braflle or on a tape. To request, call 1-800-342-5364 (DIAL-DL1) Voice or
TDD (651j 297-4196.
REI 02 (6/07)