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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 �oaa s? � ►�s o�i Owner Name Owner - InGude Area Code(s) �� �U���� ��� '�- O � �-� � uest for Electrical Ins ection Yes Inspection Other Than Rough-In: Ready Now. � Homeowner Must Schedule AII Final Ins ctions L City/Township County �,2 i rJ�� Projed Description � �rr ���r71d�, �'� �o� Gk Owner Mailing Address - Street crty �� L �m � Owner E-mail Address Electrical Utility '� ���A� �� C� U�C C,-U � N � 1 L'�C C l= L 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 �.�a 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 � �.,. - ��,�-�� �s /3-G 7 Date /z_ 2g_ 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