P - 75587tJfinnesota Dep nt of Labar and Industry
443 Lafayette ad N�rth
Sti Paul, MN 5155-4342
Phone: (65 , 284-5D64
TTY/MRS: 51) 297-4198 ,
www.ele ' .state.mn.us
Homeowner
Date Rough-in Inspeation Required?
�- I I- d Q, Homeowner Must Schedule All Rc
Address of Inspedi�n — Street
y�00 3 fd s� �
Ov�mer Name
d1�1 �f-t (� �� C� I ��
Owner Telephone Number�s) — ir
��rZ�S32- ��
Owner MaTng Address — 5treet
�
l� � rs
�de Area C+
1 �7
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOVIMER
PERMIT # � �� E% c � 2 �
RECENED: �' /�" ��
uest for Electrical Ins eciio�n
� Y� Inspeciion Off�er Than Rough-In: ❑ Ready Ncv�
Inseer�ions Homeowner Must 5chedule All Fnal Ins�ections � V�iU 5chedule
Cify+/Tawmship County
Fric(l�y ��(OYR
Projed Desaription _
�5 � � �e � Y �S � �� �.. l6ofl- �'��t f G
� p6 �M� ,�le�.��r �°�� �,1 �ooA"�r' ���F
y/6 O 3 rel s� sl/C f'. : cl le � /v�/�/ �Se/Z 1
Owner E-mail Address E��� �f�Y
� 1��,-..r..�. �� A 6� �Co.�-� ,� �� e � /-�'��a �v��R 1�/�! 9/2°���
By signing this document, I c�tfify fi�at I am the ovrner as defined by Minn. Stat § 326.01 and will legaliy perForm the electric�l v►rork
Owner 5ignature '
New Home or Associated Structure
New Home Service/Pawer Suppiy 0— 4A0 ampere @$35
New Home Seivir,elPower Sup�iy�D1 — 800 ampere @�60
— More than 30
Fee Calculation
to 3D Feeders/Circuits - �100
To 200 A Ca� $5 Each
Detached Garage or Other Associated Structur�
idew ServicelPower Supply
New FeedersJCir�ui�
Other (SpecifYl
Other
0 — 480 ampere @ $35
( ) 3(,i $6 Ead1
Existing Home/Structure Remodel or Addif3on
New SenricelPowar
�yi�'R�� �P�Y
FeederslCircurts — Ua io 15
0 — 400 ampere � $35
401 — 80D ampere @ $60
or16to30CrD$1QD
FeederslCirc�its — Mare Than 30 Feeders/Circuits
( ) Feeders/Circuits Up to 200 A@�6 Eac�
�rinected FeederslCircuits
( ) FeedersJCira�its $2 Each �
Detached Garage or Other Associated Structure
Nevv Servics/Power Supply
New Feeders✓Circ�i[s
Reconneded Feeders/Circuits
Other (Specify) .
0 — 4Q0 ampere @ $35
( )@$6Eacfi
( ) @ $2 Each
Tot'dl (the fee ca{culated above or $35 mu(tipl'ied Totdl (the fee calculate�i above or $35 muftiplied
by the number of required inspedion trips, , by the number of requhed fispec6�n trips,
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) wiifi a fee of $250 or less ezpire 12 morrths from the filing date. The owner must have the w
12 morrth pe�iod or submft another REI ihat f�ludes the inspecHon fee for the uncompleted work. Ir�spectioe fees da not carty ove�
A service e of $30 wfU be added for a0 dfshonored ch�cks.
I hereby c:ertfy fhat I inspeded the etectrical insSaflafion herefi on the dates staterl: , For Depar6nent Use nly
Rough — In Inspectio s) ' Date � �) r� �� �� ���
����—�� � � � � = % a•,c �' �i (o�' ��,
This mate�Sal can be made available in
TDD (6fi1) 297-4198.
REI 01 (6/07)
_� t� � REC'D A 11 2008
such as large print, Breille or on a tape. To request, cafl 1-800-34;
�mPteted wfthin the
one REI to another,
or