P - 76239Minnesota Depa nt of Labor and Industry
443 Lafayette R � North
St Paul, MN 5 5-4342
Phone: (651) 5Q64
TfY/MRS: ( ) 297-4188
vwauv.eledri ' .state.mn.us
��'D JUL 1 � 2001
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Contrac or Re uest for Electrical ins ection — One Famil Dwellin /Associated Structure
Date Rough-In Inspection Required? ❑ Yes Single Inspection Other Than Rough-In: [� Ready Now
�'" ���-' Contraotor Must Schedule All Rou h-In Ins eciions Contractor Must Schedule All Firtal Ins ctions ❑ Will Schedule
Address of Inspection - Street Cityffowmship County
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Oumer Name
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Owmer Teleph ne Number(s) - Include
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Contractor Nam
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Contractor Telephone Number
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Projed Desaipiion
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Contrador Maifing Address
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Contractor E-mail Address Electrical Util'ity .
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Contractor Li�nse Number Jo roject Contact Person
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Fee Calculation
New Home or Associated Structure Existing Home/Strvcture Remodel or Addition
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New Dwalling Service/PovHer Supply 0- 400 ampere �$35 New Servic8/Power Supply�vv 0- 0 ampere �$35 ��
New Dwelling Service/Povrer Supply 401 - BQO ampere @$60 New Senrice/Power Supply 401 - 800 ampere �$60
New Dwelling F�ders/Circuits ----- -- -- -- -- New Feeders/Circuits - Up to 15 FeederslCircuits —
U to 30 Feeders/Circuits -$100 FeederslCircuits $6 Each or 16 to 30 $100
New Home - More than 30 �eeders/Circ�fts (in addition to New FeederslCircuits - More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each FeederslCircuits U to 200 A $6 Each
Other (Specify) Rec�nneded Fe�ers/Circuits
FeederslCircuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 New Senrice/Power Supply 0— 400 ampere �$35
New Feeders/Circuits { ) @ $6 Each New Feeders/C'vcuits ( ) � $6 Each
Other (SpecNy) Reconneded Feeders/Circuits ( ) @ $2 Each
Other (SPec+iY) Other (SPecafY) . �
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Total (the fee qlculated above or $35 multipUed Total (the fee ralculated above or $35 multipiied
by the number of required inspection trips, by the number of required inspec�on trips, ��/'�
whichever is greater) whichever is greater) ��
Requests for Electrical Inspection (REI) wfth a fee of $250 or less expire 12 morrths from the flling date. The contractor must have the work completed within
the 12 morrth perlod or submk another REI thet Includes the inspectfon fee for the uncompleted woric. l�peetfon fees do not carry over from one REI to
another.
A serviee charge of $30 will be edded for all dishonored checks.
I hereby certify that I inspeded the electrical instatlatlon herefn on the dates stated: For Department Use Only
Rough - In Inspection(s) Date
Date
This materfal can be made avatlable in different fom�s, such as large print, Braflle or on a tape. To request, call 1-800-342-53b4 (DIAL-DLq Voice or
'fDD (651) 297-4198.
REI 02 (6/07)