P - 76680Minnesota De
443 Lafayette
St. Paut, MN
Phone: (65
TTY/MRS-
www.ele cit
of Labor and Industry
1)297-4198
.state.mn.us
' Homeowner
Date Rough-In Inspection Required?
�' —/c� - O r% Homeowner Must Schedule All Rc
Address of Inspection - Street
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Owner Name
Owner
- InGude Area Code(s)
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uest for Electrical Ins ection
Yes Inspection Other Than Rough-In: Ready Now.
� Homeowner Must Schedule AII Final Ins ctions L
City/Township County
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Projed Description
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Owner Mailing Address - Street crty
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Owner E-mail Address Electrical Utility
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By signing this document, I cert'rfy that 1 am the owner as defined by Minn. Stat § 326.01 and will legally �
Owner
New Home or Associated Structure
New Home ServicelPower Suppty 0— 400 ampere �$35
New tiome Service/Power Suppty 401 — 800 ampere @$60
New Home Feeders/Circuits
New Home — More than 30
Other (Specify)
Fee Calculation
to 30 Feeders/Circuits - $100
s/Circuits (in addition to
� To 200 A f�D $6 Each
Detached Garage or Other Associated Structure
New Service/Power Suppfy 0— 400 ampere @$35
New Feeders/Circuits
Other (Specify)
Other (Specify)
( ) @ $6 Each
Vllill Schedule
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the electrical work
Existing Home/Structure Remodel or Addition
New Service/Power Supply
New Service/Power Supply
New Feeders/Circuits — Up to 15
( ) Feeders/Circuits @ $I
New Feeders/Circuits - More Th
( 1 Feeders/Circuits
0 — 400 ampere � $35
401 — B00 ampere @ $60
30 Feeders/Circuits
to 200 A (a� $6 Each
( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Reconneded FeederslCircuits
Other (Specify� � �. �
( ) @ $6 Each
( ) @ $2 Each
Total (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied
by the number of required inspection trips, , by the number of required inspection trips, � y
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of S250 or less expire 12 morrths from the filing date. The owner must have the work completed within the
12 month period or submk another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to another.
A service char e of S30 will be added for all dishonored checks.
I hereby certify fhat t inspected the elecVical installation herein on the dates stated: For Department Use Only
Rough — In Inspectio (s) �„�,Q�te
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Date
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This material can be made available in different forms, such as large print, Braille or on a tape. To request,
TDD (651) 297-4198.
RE101 (6/07)
(DIAL-DLI) Voice or