P - 75471Minnesota Depa nt of Labor and Industry
443 Lafayette Ro North
St. Paul, MN 5 5-4342
Phone: (651) 5064
TTY/MRS: ( ) 297-4198
www.eleotri .state.mn.us
Cont ctor Re uest for Electrical Ins
Date �7 °3 Rough-In Inspeetion Required?
�.� �`� �� Contractor Must Schedule All Rou h-In
� Address of Inspection — eet
ro 3 l / �..7 ' n �� /l��
Owner Name j
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Owner Telephone Number(s) — Include Area Code(s)
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tion — One Fami
Yes Single Inspecti�
�
IIIIII IIIII
an Rough-In:
All Final Inso
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ontractor Name �., Contractor Maiung Address
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Contrador Telephone Number Contractor E-mail Address Electrical
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mtractor License Number
C A o� 3 I C�
Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — S00 ampere @� $60
Up to 30 Feeders/Circuits -
— More than 30 Feeders/Circuits (in addition to
) Feeders/Circuits Ua To 200 A Ca) $6 Eai
a.
Detached Garaue or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Other (Specify)
Other (Specify)
( ) @ $6 Each
Job/Project
IIII� IIII IIII
Ready Now
Will Schedule
�
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuiis
Feeders/Circuits $6 Each or 16 to 30 $100 !��
Plew Extended Feeders/Clrcuits — More Than 30 FeederslCircuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconne�ted Feeders/Circuits ( ) @ $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, � 5,.�
whichever is greater) whichever is greater)
--•
Requests for Electricat Inspection (REq wlth a fee of $250 or less expire 12 months from the flltng date. The contractor must have the work completed withfn
the 12 month period or submit another REI that Includes the inspection fee for the uncompleted work. Inspectfon fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dtshonored checks. �, �
I hereby certify that I inspected the electrical installatlon herein on the dates stated: For Departrnent Use Only
Rough—In Inspection(s) Date a (�b�..� ( (p�
This mateMal ca �
TDD (651) 297-4198.
REI 02 (6l07)
Date
�,.��o
3nt Torms, such as
�C`I� S � � � 0 2008
or on a tape. To request, call 1-800-3
or