P - 75664Minnesota De
443 L•afayette
St Paui, MN
Phone: (651)
TT`(lMRS: �
www.elect�it
�,-
:nf of Labor ancl Industry
North
1) 297-4188
.state.mn.us
Con ctor Re uest for Electrical !n
Date Rough-In Inspection Required?
��g�/'� Coniractor Must Sc�edule All Rou9h-
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Owner Na e
Owner Teie onE
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RESIDENTIA�E�.,E��ICAL PER �IT��Y CONTRA.CTOR
PERMIT # � �
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RECEIV�,� � � 2.�.QB
— One Famil Dwellin /Associated Structure
Single Inspection Other Than Rough-In: � Ready Now
Contractor Must Schedule All Final Inspections ❑ Will Schedule
Contrador Maiting Addres:
3�6$3 cn�4
Contractor E-mail Address
New Home or Assoctated Structure
{�t` T�'�`�'�
Fee Galculation
Mew Dwaliing Sen%ice/Power Supply 0— 400 ampere �$35
New Dwelfing Servic�/Power Supply 401 — 800 ampere a� $60
Plew Dwellin9 Feeders/Circuits — -
Up to 30 FeederslCircuits -
— More than 30 �eeders/Circuits (in addi�on to
1 Feeders/Circuits Un To 200 A(a� $6 Eai
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 4U0 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
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Electrical Util'dy
� tS�l
�tr�l sSai3
Existing Home/Struc�ure Remodel or Addition
New 5ervice/Power Suppy
New 5ervice/Power Supply
Alow F�ur�are/f _irr� id�s — I ln
0 — 40D ampere � $35
401 — 8D0 ampere @ $60
Eachor16to30(�D$100
to 200 A(a� S6 Each
Detached Garage or Other Associated Structure
New Senrice/Power Suppiy 0— 400 ampere @$35
New Feeders/Circuits
Reconnested Feeders/Circuits
( ) @ $6 Each
( ) @ $2 Each
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Total (the iee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied
by the number of requiretl inspedion trips, by the number of required inspec�fion trips, `�� Q
wrhichever is greater) whichever is greater) %
Requests for ElecUical inspection (REI) with a fee of $250 or less expire 12 months from the ftling date. The contractor must have the work completed w in n�
the 12 month pe�lod or submk another REI that fncludes the Inspectlon fee for the uncompleted work: InspecUon fees do not carry over from one REI��IJ
another.
A servtce charge of $30 wfll be added for all dishonored chacks.
I hereby certify that I inspeGed the el�trical installatinn herein on the dates stat�: For Departrnent Use Only
Rough — In Inspection(s) Date ��,
� . �,1� .S'-� �= .
Finallnspe ' Date u
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This mate al can be made available in dffferent forms, such as large print, Braille or on a tape. To request, call 1-600-342-5354 (DIAL-DLl) Voice or
TDD (657} 297-4196.
REI 02 (6/07)