P - 75275���
�innesota Depa f t of Labar and Industry
443 Lafayette R � North
Sti Paul, MN 55-4342
Phone: (659 5064
TTY/MRS: 1 } 297-4198 .
www.ele .state.mn.us
Homeowner
Date Rough-in lnspecfion Required?
g°3o '�� Hnmeowner Must Schedule All Rc
Address of inspection — Street
%�/�3 ����e ��'_
Owner Name �
c` 1/'G � � � �/.t.54� �. � /�
Owner T phone Number(s) — include A
�,�'S7/-8'/es�� �C�e��%/Q/o?-
Owmer Mailing Address — 5treet
15��3 � ���� e � �
Owner E-m/ail Addi
vrr�rlD�S
By signing� th doc
0
eSC�v�
- /�3�'r 7
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT# U�V6� -�I� O�
RECENED:
uest for Electrical Ins ectib�n
� y� Inspecb�n Ofher Than Rough-!n: ❑ Ready N�v�
Inspeciions Homeowner Must Sdiedule All Fnal lnsnections � V�iU 5chedule
....��.'� �r� e y .....��.0 �C�..
Projed Description �� a o w Ba.H.��a /?iovc /� r,�. �.� �'�� �
11 > / ao
1'zc� �e{oa ca�w �.i�l�{�s \�Cifet�eK� 2 1�l��s OJer jG�e le�..
19�a.i..c�) �`iD ���w-Ls �v.,�<i4z�e�.. �,,.V-e�� Ce'����:��caw�L`��i-
�'aw.:,ly fca�,,,` wi.o e ��eve�2e�'� A�Sh�o:s(�er �
atir b�.oc e'��� oa5 ��� 4s�� ( i� i�-. $�.e k Poo r�° lo se-F
C �
( State Zip Code
�r � d�e S� � U�-uL S S`� 3�
I
co-r�.��.,�°� o �� x��
I c�rtii'y that I am the owner as defined by Minn. Stat § 326.01 and will
New Home or Associated Structure
New Home Servic�/Pawer Supply 0— 400 ampere @$35
- —T�leurTiorr��enriceiPower S'uPpi9-4�1 =&0@amPEre @-$fi9
New Home — More than 30
Oifier (Specify)
0
perform the electrical work
Fee Calculation
Existing Home/Structure Remodel or Addifi3on
New Service/Povv�r Suppfy �— 400 ampere �$35
-Servi�iPeaaet �qpp� -- "^�;--nd9:aFnpere � $SD
New Feeders/Circuits:- Up to 15 FeedersJCircuits
to 30 Feeders/Circuits -$100 FeedersdCircuits $6 Each or 16 to 30 $100
s/Circuits (in add'Rion to iJew FeederslCircufts - Nfore Than 30 Feeders/Cira�its •
p To 2D0 A@$6 Each ( ) Feeders/Ciraiits Up to 2D0 A CrD_ $6 Each
Detached Garage or Other Associated Structure
New Servic�/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
Other (SpecifY)
Other
( ) FeedersJCircuits $2 Each I
Detached Garage or Oiher Associated Structure
New 5ervice/Power Supply 0— 400 ampere @$35
New Feeders/Cira��its
Reconneded Feeders/Circuits
( ) @ $6 Each
( ) @ $2 Each
Total (the fee calculated above or $35 muftiplied Total (the fee cald�lated above or $35 muftiplied
by the number of required inspection trips, ' , by fhe number of required inspection trips, �,'�j��
whichever is greater) whichever is greater) , us�
Requests for Eiectrical Inspecfion �REI) with a fee of $250 or less ezpire 12 monttss from the filing date. The owner must have the work completed wfthin ihe
1 Z month period or submit another ItEt that inciudes the Inspezfion fee for the uncompieted work. lnspeefion fees do not carry over from one REI to another.
A service ch e of $30 will he added for all dishonorad cn�cks.
I hereby certHy fhat I inspeG� the elettrical instalfat3on herein on the dates stated: For Department Use Only
Rough — In Inspe ' s} ' . Date
/5���
Finallnspection Date .
_3 °�/ _ � �'
Tfiis material can be made available in different forms, such as large print, Braille or on a tape.� To req est, cafl
TDD (651) 297-419& °��
RE101 (fi/07) �
��
or