P - 75345Minnesota Department of Labor and Industry
443 Lafayette Road North
St. Paul, MN 155-4342
Phone: (651 84-5064
TTY/MRS: 51) 297-4198 .
www.ele ty.state.mn.us
Cont ctor Re uest for Electrical
�Da . _ Rough-In Inspedlon Required?
� V Contrador Must Schedule All Rou
Addresspf �n�pedion_ St�eet 0 � _
Owner
�
s ection — One Famil Dwellin /Associated Structure
Yes Single Inspectlon Other Than Rough-In: Ready Now
n(nspections Contractor Must Schedule All Final Insuections n Will Schedule
�
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Project Description
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� Fee Calculation
� New Home or Associated Structure ' Existing Home/Structure Remodei or Addifion
New Dweiling Service/Power Supply 0— 400 ampere @$35 • New ServicelPower Supply 0— 400 ampere @$35
New Dweliing Service/Power Supply 401 — 800 ampere �$60 ' New Service/Power Supply 401 — 600 ampere �$60
Pdev� Dwelling Feeders/�i�u+ts New/Extended ��efslCircuiEs — Up ta-15 Feeders/Cirsuits
U to 30 Feeders/Circuits -$100 Feeders/Cfrcufts '$6 Each or 16 to 30 $100
New Home — More than 30 Feeders/Circuits (in addi�on to New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
Other (Specify) '
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New FeederslCircuits ( ) @ $6 Each
O:her (SRe:.ifv) .
Other (Specify)
( ) Feeders/Circuits @ $2 Each �
Detached Garage. or Other Associated Structure
New Servlce/Power Supply 0— 400 ampere @$35
New/Extended Feeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) � $2 Each
Total (the fee calculated above or $35 multiplfed Tot81(the fee calculated above or $35 multiplied
by the number of required inspection trips, by the number of required inspection trips, •
whichever is greater) • whichever is greater)
Requests for Electrical InspecUon (REI) with a fee of 5260 or less expire 12 moriths from the flling date. The contractor must have the
the 12 month period or submk anoEher REI that Includes the InspecUon fee for the uncompleted work. InspecUon fees do not carry
anothar.
A service charge of =30 wlll be added for all dtshonored checks. �
I hereby certify that I inspected the electrical installatlon hereln on the dates stated: For Deoartment Use �nlv
Rough — In Inspedion(s)
This material ca?t-lf�made 3v�11able (n different
TDD (651) 297-4198. •
oci n� �c�n��
Date
Date
o� �,�
as large pi
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�REC'p MAY 2 9 2008
or on a tape. To request, call 1-800-
�
r� •
pleted within
one REI to
or