P - 75309Minnesata Depariment of Labor and Industry
443 Lafayette Raad NQrth o
Sti Paul, MN 55155-4342
Phone: (651)E2845D64
TTY/MRS: (, 1) 297-4196 ,
v�naw.electn�.state.mn.us
Homeowner
Date Rough-tn fnspedion Required7
���.t1lJ' �� Homeowner Must 5chedule All Rc
e.�a��� „f I.,�.wri;nn _ Str�t
�+nmer Name
�
�c.z�c�.�t:. 1� i.
Owner Telephane Number(s) — InG
C"Ib��� S�F�('Z�
Owner MaTng Address — 5'treet
5 v� +� Met� Sk
Ov�mer E-mail Addr�s
By signing
Owner Sig
)I
4re
3
�
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT #
RECENED:
uest for Electrical ins ectib-n
� Y� InspecEi�n Oit�erThan Rough-In: ❑ Ready Nov�
i����-�;nns Homeowner Must Schedute All Final Insaections ❑ V►�n Schedule
'rojed Description0
�C�S c�0.l�G�S• J� `�V � � S �G �
r�7•�n G ��� > /� � l �� �17
;�yy State Z�F
�r � `\L,�--�-► vv� 1�...� `s�
I csrtify fhat I am the owner as deflned by Minn. Stat § 326.D1 and v�nlf Iegally pertorm me eiectncai wonc
New Home or Associated Structur�
New Home SenricelPawer Supply 0— 40D ampere @$35
Idew Home Senric$lPower Suppty 4D1 — 8D0 ampere @$60
�
Fee Calculation
ExYsting Home/Structure Remodel or Addifion
New Setvice/Power Supply 0— 400 ampere �$35
New SQnric�/Power SupPiy 401 — B00 ampere @$60
u�r �r�orelt:imiiFe — 11e 4e 15 FeedersfCircuits
t} to 30 FesderslCircvits -$1DO Feeders/Circu�s $6 Each or 16 to 30 $1OD
New Home — More than 30 FeederslC'rccuits (in addition to New FeedersiCircufts - More Than 3D Feeders/Circwits
above FeedersJCircuits U To 20D A $6 Each FeederslCircuits U to 20D A $6 Each
Dtt�er (Sper.ify) Reca►inecied FeederslCircuits
. Feeders/Cira�its $2 Each
Detached Garage or Ofiher Associated Structur� Detached Garage or Other Associated Structure
New ServicelPower Supply 0— 4d0 ampere @$35 New Service/Power Supply 0— 400 ampere �$35
New Feeders/C'u�cuits ( ) @ S� �d� Neav Feeders/Cira�its ( ) @ $6 Each •
Qther (Specify) Rec�nneded FeederslCircu'rts ( ) @ $2 Each
Other (SpecifY) � Other (SPecffY) . , �� �
Total (the fee calculated above or $35 muitlplied Total (the fee calailated above or $35 muftiplied
by the number of required inspedion frips, , by the number of required inspe�tion trips,
whichever is greater) whicheVer � greater) ���
Requests for Electrical Inspeztion (REI) with a fee of $2S0 or less ezpire 12 months from the filfng date. The owner must have the work completed wfthin the
12 morrth period or submk another REI tiiat ineludes the inspeetion fee for the uncompleted work. Inspedion fees do not carry over from one REI to another.
A service cha e of $30 will he added for all dishonored checks.
I hereby certiy 9iat I inspected the et�trical instaUation herefi on tlie dat� stated: For Department Use Only
Rough — In Inspection(s) ' Date �i��� �
s macena� ean b
TOO (651) 297-49gg,
REI01 (6/O�
Date
forms, such as large
� �1.� ✓
�� �� � � �
�oa�
or on a tape, Tn �e4��� ca1l 1.8en_�.►� ..
,
i
V01'� , .
9
/,
�