P - 76906Minnesota Depart nt of Labor and Industry
443 Lafayette R North
St. Paul, MN 55-4342
Phone: (65 84-5064
TTY/MRS: 51) 297-4198
www.ele ity.state.mn.us
Contractor Re uest for Electrical Ins
Date Rough-In Inspection Required?
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i V����/ Contractor Must Schedule All Rou h-In
Address of Inspection - Street
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� Owner Name
� Owner Telephone Number(s) - Include Area Gode(s)
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�c�n Nov � 4 2oa�
tion — One Famil Dwellin /Associated Structure
Yes Single Inspection Other Than Rough-In: ❑ Ready Now
�ctions Contractor Must Schedule All Final Ins ections Will Schedule
City/Township County
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nC� tractor Name F Contractor Mailing Address
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Contractor Telephone Number Contractor E-mail Address
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e ical Utility
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Contractor �icense Number .lob/Project Contact Person
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Fee Calculation � ` € � �
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New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — S00 ampere @$60
New Dwelling FeeQer5lCircuds - - - �
Up to 30 Feeders/Circuits - $10
New Home — More than 30 Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A@$6 Each
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Other
( ) @ $6 Each
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Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
itilewFa�ie�s/Circuiw—Up.o ��Feeder�f.^.ircui4s
( ) Feeders/Circuits @$6 Each or 16 to 30 @$100
New Feeders/Circuits — More Than 30 Feeders/Circuits
( ) Feeders/Circuits Ua to 200 A C� $6 Each
( ) Feeders/Circuits @ $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Reconn�cted Feeders/Circuits
( ) @ $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, 3s �
whichever is greater) whichever is greater)
Requests for Electrlcal Inspection (REI) with a fee of 5z50 or less expire 12 months from the flling date. The coMractor must have the work completed wffhin
the 12 month period or submit a�other REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of S30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installation herein on the dates
Rough — In fnspection(s) Date
Final
This material can bE
TDD (651) 297-4198.
REI 02 (6/07)
avaflable in different forms,
For oepartment use on�y
G- � � I
as large print, Breille or on a tape. To request,
(DIAL-DLq Vo1ce or