P - 75382• Minnesota Departrt�%nt of Lab�r and Industry RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER I
4�4�3 Lafay�tte Ro�d Norih PERMIT #
St Paul, MN 55��� � 2 �
Phone: (651) 2 5D64 RECENED:
TfY/MRS: (65 297-4186 ,
wwvw.elec�ri ' . tate.mn.us
Homeowner Re u st for Electrical Ins ectio-n
Date Rough-In lnspection Required? Yes ��P��n QiherThan Rough-In�. � Ready Nov�
As �,i'cu� d,,5t�y� a�o,aah �n d- r'w+„� a�+ �,+►z '�+�,tl,
� t � 1 � Homeowner Must Schedule All Rou h-Ih lns e�iions Homeowner Must Schedule Ail Fnal tns ections �V�ill Schedule
AddrESS of lnspection — Street C'�tylfowmship Caunty
�j � � �D�� !"t1P� L � t ► �
Ov,mer Name \ Pro}ed Descripti n _ �q
J Jo G` .� �i�►� ��Pt �4��,► ►��u. �►+� g� � �- hea�,�
Owner Teleph�ne Number(s) — Include Area Code(s) �
7t�3 °V10 � `l� �b J� e�e�1
Owner MaTng Address — 5treet " City State Zip Code
ej' ��� ��`�' � 1 � ' S"S��3o�
Oamer E-mail Address Electrical fity �
' L , n �t � XG�' .
By s�gning this docx�ment, I ce+iify fhat i am the owner as defined by Minn. Stat § 326.01 and wnU legaliy pertorm the electrical work
r Signatu ,
Fee Calculation
New Home or AssacEated Structur� ExisEing Home/Structure Remodel or Additian
New I-Fome Senric�/Power SuPPh' �— 400 ampere @$35 New Servic�lPower SuPPh' 0— 4U0 ampere �$35
hlew HQme ServicelPower SuPPN 4D1 — 800 ampere @$6D New 5ervic�/Pow�er SuPPIy 401 — BOD ampere @$60
Ne�nr Horr� Fe�lers/Cira�its New FeederslCircuits — Up to 15 FeedersfCircuits
U to 3D Feeders/CircUits -$100 �'�¢: Feeders/Circu�s �6 Each or 16 to 30 $1a0
Idew Home — More than 30 FeederslCircx�its (in add�fon to 1Jew Feeders/Cirwits - More Than 30 FeederslCiraiits
above FeedersJCircuits U To 200 A $6 Each Feeders/Circa�its U to 20D A $6 Each
Other (Specify) Recaen�Yed Feeders/Circuits
FeedersJC'rc�uits $2 Each
Detached Garage or Other Associated Structure Deiached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35 Newr Service/Power Supply 0— 400 ampere �$35
New FeedsrsJCifcuits ( ) � $6 Each New Feeders/Circ:uits ( ) @ $6 Eac� �
Other (Spec�fy) Reconnected Feeders/Circu'its ( ) @ $2 Each
Other (Specify) � Other (SPecifY) • � � `a J ��
Total (the fee ca{c�lated above or $35 muf6plied Totdl (the fee calailated above or $35 muftiptied
by the number of required inspec6on trips, , by the number of_required inspection trips, s`� /`�
whichever is greater) whicheVer is greater) +� ��
Requests fw Electrical Inspect}on (REI) with a fee of $250 or less e�cpire 12 motrths from tfie filfng date. The owne� must have the work completed withfn the
12 morrth pe�lod or submk another f2E1 that fnciudes ihe i�spection fee for the uncompleted woric Inspecfion fees do not carry over from one REI to another.
A service e of $3D wiil he added for aIl d[shonored chpcks.
I hereby cerNfY fhat I insped� the el�tricai instaAatian herefi on the dates stated: �,/ ��� p�_ p Use Only
Rough — In Inspection(s) ' �\y
Date ��d ��L
1. l3
Final Inspection �, Date • It[� �Q v 1ffi z0o0 •
This mate�fal can be made available in different forms� c� la Braflle or on a tape. To request, ca(I 1-8�0-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-419B.
REI 01 (6l07)