P - 75193Minnesota Depart nt of Labor and Industry
443 Lafayette Ro North
St. Paul, MN 55 5-4342
Phone: (651) 2 -5064
TTY/MRS: (6 297-4198
www.elecfici tate.mn.us
Contra or Re uest for Electrical Ins
Date � � Rough-In Inspection Required?
2 0 Contractor Must Scbedule All Rou h-In
Ad r ss f Ins ection treet
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Owne Name
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Owner Telephone Number(s) - Include Area Code(s)
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Co ctor Name • Contractor
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r ctor Telephone Number
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ra�or Au�7�{ized Signature
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REC'D D E C 12 2007
tion — One Famil / Dwell
Yes Single Inspection Other Th,
Contractcy Must Schedule All Final Ins e
ty/To ship County
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'oject Description
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Address
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Structure
Ready Now
� Will Schedule
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� License Number Job/Project Contact Pers n
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Fee Calculation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Dwelling Service/Power Supply 0— 400 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60 New ServicelPower Supply 401 — 800 ampere @$60
- — 6-- — —
u_... r...._n:__ r�_��...ir:.....:�.. � - AlniulGv►cnrlcri �corlurc/Rircni4s — 1 In }n 1.ri�PRC�(1fS/rI�Cl1ItS
Up to 30 Feeders/Circuits - $
— More than 30 Feeders/Circuits (in addi6on to
1 Feeders/Circuits Uo To 200 A CrD $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (Specify)
Other (Specify)
FeederslCircuits @$6 Each or 16 to 30 @$100
ied Feeders/Circuits — More Than 30 Feeders/Circu
) Feeders/Circuits Up to 200 A@$6 Each
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New ServicelPower Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify)
X� / V
Total (the fee calculated above or $35 multiplied Tot81(the fee calculated above or $35 multiplied �
by the num6er of required inspection 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 filing date. The contractor must have the work completed wkhin
the 12 month period or submit anoYher REI that includes the inspection fee for the uncompleted work. lnspection fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
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I hereby certify that I inspected the electrical installation herein on the dates stated: Fo� Depaltment Use Only
Rough - In Inspection(s) Date �
This materia can be made available In different forms,�such as large print, Braille or on a tape. To request, call 7-800-342-5354 (Dlw�-uu) voice or
TDD (651) 297-4198.
REI 02 (6/07)