P - 75577Minnesota Departm
443 Lafayette Road
Sti Paul, MN 5515E
Phone: (651) 284-�
TTY/MRS: (651)
Labor and Industry
-4198
mn.us
Homeowner
Date �� �tough-tn inspection Required?
Homeowmer Must Schedule All Rc
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� J Owner Name
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er Telephone urnber(s) — Include Area C�de s'
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RESIDENTIAL ELECTRICAL PERM BY HOMEOWNER
PERMIT # � l���°` �
RECENED:
uest for Electricai Ins ectio�n
� y� Inspecfion Other Than Rough-In: ❑ Ready Nov�
Ins 'ons Homeowner Must Schedule Ail Fnal Ins ctions 1/�i115chedule
City/Townshjip_ County ,
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Owner MaTng Address — Stree4 City State ____
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Owner E-mail Address Electric.al Util"ity
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By signing this doa�ment, I cerrliffy that 1 am the ovmer as defined by Minn. Stat § 326.01 and wili legalfy perform the electrical work
Owner Signature �
Fee Calcutation
New Home or Asseciated Structure
New Home Senrice/Power Supply 0— 4U0 ampere @$35
New Home Service/Power Suppy 4D1 — 800 am�era @$6D
New Home Feeders/Ci�its
Up to 3D FeedersJCircuits - $
— More than 30 Feeders/Circuits (in eddition to
1 F�ierslCirt�its Un To 2�0 A(v� $6 Each
Detached Garage or Other Associated Structure
New Servic�//Powrer Supply
New Feeders/Circuits
0 — 400 ampere @ $35
( ) @ $6 Each
Existing Home/Structure Remodel or Addi�ion
New Servic�lPovuBr SuPPIy /,�,,, ��`— 400 ampere ��35
Piew Setvic�iPovver Supply 4Q1 — 800 �mper� @$60
New FeederslCircu�s — Up to 15 FeedersJCircuits
( � ) FeedersJGircu�s @$6 Each ar 16 to 30 @$100
iJew FeederslCircvits — More Than 30 FeederslCirwits
( ) Feeders/C'vcuits Ua to 20D A(cil $6 Each
Detached Garage or Other Associated Structure
New 5ervicelPower Supply
New Feeders/Circx�its
Reconnected Feeders/Circuits
Other (Specify) .
0 — 400 ampere @ $35
( ) @ $6 Each
( ) @ $2 Each
Tot31 (the fee calailated above or $35 mul6plied Total (the fee calculated above or $35 muttiplisd
by the number of required inspection trips, , by the number of required inspection trips,
whichever is greater) whichever is greater)
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Requests for Electrical Inspecfion (REI) with a fee of �250 or less ezpire 12 morrths from the fiiing date Th owner must have the work wmpleted within the
12 morrth period or submft another REI ihat inciudes the irtspeztion fee for the uncompleted work. Ins on fees do not carry over from one REI to another.
A service char e of $30 will ba added for all dishonore hecks.
� hereby certify {hat I insped� the el�trical instaliation herein an U�e dates staR�: For Department Use Only
Rough — In Inspection(s) ' Date
,
c:.,,i i.,� e� _ �, Date a
Thisyha%riaYc`an be
TDD�(651) 297-4198.
REI 01 (6/0�
���— J - ��'.�
ile in different forms, such as large
� ��,
or on a tape. To request,
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