P - 75412Minnesota Depa nt of Labor and Industry
443 Lafapette R �North
Sti Paul, MN 155-4342
Ph�ne: (651 84-5D64
T1Y/MRS: 51) 297-4198 ,
www.ele ' .state.mn.us
Homeowner
D Rough-In Inspec6on Requir�d7
�� �I�� Home�wner Must Schedule All Rc
Address of inspedii�n - treet `
��s c��� � ��—
Owmer Name
�
Owner Teleph
� �� �
Owner Ma►Tinc
�`1 �
bamer E-mail
. _
gY
�umbe�(s) - Inctude Area
� l l��
��t I��
I
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT #
RECEIVED:
uest for Electrical Ins ectib�n
� Y� Ins �n er� Raugh-ln: ee�ue ' Ready N��
���n� Fiwa) a� �°H� ds .
i���A,-r;��� HemQ_ewner Must Schedule All Fm�t In�peciions ❑ V�p St�edu{e
•-,--- -- -- �--
IS{�crrwt}1� ; �S ��j � �eZ�fd �:
� c �i��. f�2�e� '� ��
� ` 1
����
I the ovmer as defined by Minn. Stat § 326.01 and wnp
New Home or Associated Structure
New I-F�me Service/Power SuPP�!' �- 400 ampe2 @$35
Plew Home Servic�/Power Suppy 401 - 800 ampere @�6D
- More than 30
A
�-
to
neF�..tie� r_��.,p r;r cN�her Associated Structure
New ServicelPower Supply 0- 400 ampere @$35
New FeederslCircuits
Other (Specify)
Other (Speci(y)
( ) @ $6 Each
the eleetrical work
Existing Home/Structure Remodel or Addii�ion
New Seni►celPouver SuPPIy 0- 400 ampere @$35
Newr Senric�/Power Supply 401 - BOD ampere �$60
Ne�v Feeders/C'vwrts - Up to 15 FeedersJCircuits
FeedersJCirar�s $6 Each or 1fi to 30 $10D
�Nevn FeederstCircuits - More Than 3D Feeders/Circuits
(�) Feeders/Circ�ifs Ua to 20D A(� S6 Eac�
( ) FeedersJCircuits @ $2 Each �
Detached Garage or Other Associated Structure
New Servi�/Power Suppiy 0- 400 ampere @$35
New Feeders/Circuits ( ) � $fi Each •
Re�nnected FeederslCircuits ( ) @ $2 Each
Total (the fee calcutaffid above or $35 muftiplied Tot'al (the fee calculate�i above o� $35 muttiplied S'o
by the number of required inspection trips, , by the number of required fnspection trips, � ��
whichever is greater) wh�heVer � greater)
Requests for Electrical Inspectlon (REI) wlih a fee of $25U or less expfra 72 morrths from the filfng date. The owner must have the work completed wfthln the
12 mo�rth period or submk another t2El that includes the irgpettlon fee for the uncompleted work. Inspectlon fees do not carty over from one REI to another.
A service e of $3D wN be added for all dfshonored choalcs.
I hereby certii�' fhat I inspeded the el�trical 6�sta�On herefi on the dates staded: For� Use O�y �
Rough - In Inspection(s) ' Date �
r,J
Final Inspection Date �� � � � o `� �oo�
"� - �`S'0�'
This material can be ma available in different forms, such as large print, Bralll n a Yape. To request, call 1-600-342-5354 (DIAL-DLI) Voice or
TDD (651) 29T-4196.
REI 01 (6/0'n