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Ninnes�ta Dep ent of �abor and Industry � " RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
443 Lafayette ad North PERMIT #��( )/�1.���`1
St. Paul, M 155-4342 � , • n c�
Phone: (6 284-5064 RECEIVED: I�CI. U� t 1 U �+ � 2��7
TTY/MRS: (651) 297-4198 ,
www.electricity. state.mn. us
Homeowner Re uest for Electricaf Ins ection
Date Rough-{n Inspection Required? Q Yes Inspecti�n OtherThan Rough-in: � Ready N�w
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%�" Homeowner Must Schedule All Rou h-In Ins ections Homeowner Must Schedule All Final !ns ections Wil Schedule
Address of Inspection - Street City/T�wnship� County i
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Ovr�r �tame ; � . � '' Project Description � �
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Owner Telephone Number�s) — Include Area Code(sj " � �. c� G.1 cy :..� C� f �
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Owner Mailing Address — treet City State Zip C�de
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Owner E-mail Address Electrical U61ity
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By signing this document, I c.�tii that I am the �wner as defined by Minn. Stat § 326.01 and will legalfy perform the electrical work
Owner Signaftrre j;'' l f�^.-�
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Fee G`a{cutation
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home Service/Power Suppiy 0- 400 ampere @$35 New Service/Power Suppfy 0- 400 ampere @$35 I
New Home Service/Power Supary 40t -80� a�re�ID�60 -�3ervic�/PowerSuppiy 401 - SOD ampere �$5� '
New Home FeederslCircuits New Feeders/Circuits - Up to 15 Feeders/Circuits
U to 30 Feeders/Circuits -$100 Feeders/Circuits $6 Each or 16 to 30 $100
New Home - More than 3D Feeders/Circuits (in addftion to �New Feeders/Circuits - More Than 30 FeedersJCircuits
above Feeders/Circuits U To 2�0 A $6 Each Feeders/Circuits U to 20D A $6 Each
Other (Specify) Reconnected Feeders/Circuits
Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0- 400 ampere @$35 New Service/Power Supply 0- 400 ampere @$35 , ��
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New Feeders/Circuits ( ,/,�j ) @ $6 Each New FeederslCircuits ( � ) @ $6 Each /'�-7^�
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Other (Specify) Reconneded FeederslCircuiFs �
( �- ) @ $2 Each . (/'��
Other (Specify) Other (Specify) . , 1
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To�21 (the fee calculated above or $35 multiplied Total (the fee calculated above or $35 multiplied
2 �! �—f �
by the number of required inspection trips, , by the number of required inspection trips, �� J
whichever is greater) whicheVer is greater)
Requests for Electrical Inspection (REI) with a fee of $250 or less expire 12 months from the filing date. The owner must have the work completed within the
12 month period or submit another REI that includes the inspection fee for the uncompleted worlc. Inspection fees do not carry over from one REI to another.
A service char e of g30 will he added for all dishonored checks.
I hereby certify fhat I inspected the electrical instatlation herein on the dates stated: For Department Use Onfy
Rough - In Inspection(s) Date
% Date .
Final Inspect�n
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This aterial can be ma e availabte in different forms, such as large p'nt, Braille or on a tape. To request, call 1-800342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4'f98.
REI 01 (6/07)