P - 75611♦ ./�
Nfinnesota De ��rtrnent of Labor and Indusiry RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
443 Lafaye r Raad Norifi
Sti Paul, , 55155-4342 PERMIT # ��'�����
Phone: ( 1) 284-5064
TTY1M . (651) 2s7-4158 RECENED:
www.e 'city.state.mn.us
Homeowner Re uest for Electrical Ins ectio�n
Date Rough-In Inspecii�n Required? ❑ Yes �nspecfion OfherThan Rough-fn: ❑ Ready Nov�
�/Z � Homeowner Must Schedule Ail Rou h-Ih Ins ctions Homeowner Must S�hedule All Fnal !ns ctions ❑ V�iU Schedule
Add of nspeciion - S t � City/Tovm hip County
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Oumer Na e Projed Des ' iion
�'F �,Jir F �D�rO'or� .� I<i-1'c�,�r,
er Te hone Number(s) - include Area Code(s) .
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Owmer MaTng Address - Street City p State Z�p Code
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Owner E-mail Atidress Electrical Uti'(ity
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By signing is dacument, I c�tfify that am the owner as defined by tdfinn. Stat § 326.01 and will legally perform the eledrical wQrk
Owner Signature
Fee Calculation
New Home or Asseciated Structure Existing Home/Structure Remodel or Addifian
New Home Servi�/Power Suppfy 0- 4D0 ampere �$35 New Setvice/Pawer Supply 0- 400 ampere �$35
New Hort�-ServicefF�vver Su� w6� - - - -� - ur-�ervice/Power Su�4y— - -.4U�-� B0D art�pere �-$6D _ , --
New Home Feeders/Circuits �\ New Feeders/Cira�its - Up to 15 Feeders/Circuits
U to 30 Feeders/Circuits -$100 Feeders/Ciraiits $6 Each or 16 to 30 $100
New Home - More than 30 Feeders/Circ�ifs (in addition to iJew Feeders/Cira�its - M�re Than 30 Feeders/Circuits
above FeedersJCircuits U To 200 A $6 Each Feeders/Circuits U to 20D A $6 Each
Other (Speciy) Recorinected FeederslCircuits
� Feeders/Circuits $2 Each
Detached Garage dr Other Associated Structure Detached Garage or Other Associated Structure
New ServicelPower Supply 0- 400 ampere @$35 New Service/Power Supply 0- 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Ead1 New FeedersJCircvits ( ) @ $6 Each •
OU�er (Spe�ify)
Reconnected Feeders/Circuits ( j @ $2 Each
Other (Specify) ' Other (Specify) .
To1�l (the fee calcutated above or $35 multiplied Tot81(the fee cala�lated above or $35 multiplied �
by the number of required inspecqon trips, , by the number of required inspection trips, 70 �
whichever is greater) whizhever � greater) .
Requests far Electrical Inspec8on (REI) with a fee of �250 or less expire 12 morrths from the filing date. The owner must have the work completed within the
12 mo perj o or sutimFt another REI that es the inspecdon fee for the uncompleted work. Inspe�etion fees do not carry over from one REI to a�other.
'�1� �'f,�'''� v A� �� `A selWce cha e of $30 will be added for ail dishonored ch�cks.
I hereby certify fhat I inspect� the electrical installaEion herein on �e dates stat�: For Depa ep�ry
Rough - In Inspection(s) ' � E /�Date �p_��� � ��I'� R ' �
� �Y�/J / i � �.
Finallnspectio �. Date . �
� �� �
This materiat can be made available in d'ifferent forms, such as large prin raille or on a tape. To request, call 1-600-342-5354 (DIAL-DLI} Voice or
TDD (651) 297-4196.
REI 01 (6/07)