P - 76845IJinnesota Dep eni of Labor and Industry
443 Lafayette ad North
Sti Paul, MN 155-4342
Phone: (651 84-5064
TTY/MRS: ( 1) 297-4198 ,
wwvr.electricity.state.mn. us
Homeowner
Date Rough-In lnspeciion Required?
7' �`0 � Homeowner Must 5chedule All Rc
Address of Inspection - Street
,,,�����-�-+- C- -
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT # ,�(�t/� �I �I � `T
0
RECEIVED: i?Gf'�i1 C c D �fnn�
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:e uest for Electricai Ins ection
Yes Inspecti�n OtherThan Rough-tn: � Ready Now
Ih-In Ins ections Homeowner Must Sohedule All Fina� Ins ections ❑�ill 5chedule
/ � r CitylT�shJ���� Cou�
z
�wn r Name , rro�ect �escnpnon�
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�wner Telephane Number(s) – Inctude Area Code(s) ��L�'�� CJ .
� 6 3- 6 a � �s
Owner Maifin Address – Street Ci State Zip Code
� ` � ,v�' � � � h . S��?�
Owne E-mail Address �- Electrical Utitity
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By signing this documen�rtify that the owner as defined by Minn. Stat § 326.01 and will legaliy perform the electrical work
Owner 5iqnature /` . —,,..__
Fee Cafculation
New Home or Associaied Structure
New Home Service/Power Supply 0- 400 ampere @$35
New Home Service/Power Supply 401 - 800 ampere @$60
New Home Feeders/Circuits
Up to 30 FeederslCircuits - $100
New Home - More than 3� Feeders/Circuits (in addition to
above) ( ) Feeders/Circuits Up To 200 A(a� $6 Each
Other
Detached Garage or �ther Associated Structure
New Service/Power Supply 0- 400 ampere @$35
New Feeders/Cirwits ( ) @ $6 Each
Other (S�ecifvl
Existing Nome/Structure Remodel or Addiiion
New Service/Power Suppiy 0- 400 ampere @$35
M11ew 5erviceJPow�l` Su�piy - 4D1 - 8U0 �mpere � 380
New Feeders/Circuits - Up to 15 FeederslCircu
( ) Feeders/Circuits @$6 Each or 16 to
idew Feeders/Circuits - More Than 30 Feedersl
( ) Feeders/Circuits Uo to 200 A fcD
1
Each
( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New 5ervice/Power Suppiy 0- 400 ampere @$35
New Feeders/Circuits
Reconnected FeederslCircuiEs
Other (Spec'ify)
(
�
) @ $6 Each
)@$2Each
Tot81 (the fee calcutated above or $35 multiplied Total (the fee calculated above or $35 multiplied
by the number of required inspection trips, , by the number of required inspection trips, y�7�
whichever is greater) whichever is greater) ,,)lJ
Requests for Electrical Inspection (REI) with a fee of $250 or less expfre 12 months from the filing date. The owner must have the work compteted within the
12 month period�vsubmit another REI that includes the irtspection fee for the uncompleted work tnspection fees do not carry over from one REI to another.
A service char e of $30 will be added for aIl dishonorad checks.
I hereby certify fhat I inspected the el�trical installation herein on ihe dates stated: For Department Use Only
Rough - In Inspecf r�s� Date
�% 1 � 1�- �/i ` a�
Final Inspecfion
This material can be made avaifable in
TDD (651) 297-4196.
REI 01 (6/07)
as large print, Braille or on a tape. To request, call i-B00-342-5354 (DIAL-DLIj Voice or