P - 75147Nfinnesota Depariment of Labor and Indusfry
443 Lafayette Road N�rth
Sti Paut, MN 55155-4342
Phone: (659) 284-5064
TfY/MRS: (651) 297-4198
wwwr.electricity.stafe.mn.us
Homeowner F
Date R�ugh-In Inspection Required?
2 Z� �� Homeovrner Musi 5chedule All Rouc
Ad ress of inspection — Street
60 �5 � �� ��z. � �� �-r,b�c
Owner Name �
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Owner elephane Nurnber(s) — Include Area Code(s)
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Oamer MaTng Address - Street
Owmer
By
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT # ,-�� �� c� -� �5� / i�
RECENED: � � `'�a �
uest for Electrical Ins ecfib�n
� Y� Inspeciicn OiherThan Rough-In: ❑ Ready Nov�
Ins ctions Homeowner Must Schedule Ail Fnal Ins ctions ❑ N�iU Schedule
City/Township County
Projed Descripfion .
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doaximent, I cerFify that I am the owner as defined by Minn. Stat § 326.01 and will legalfy perform fhe electrical v►rork
New Home or Assaciated Struature
New Home Seniice/Power Supply 0— 400 ampere �$35
New Home SenricelPower SuppTy 40i — 800 ampere �$6D
to 30 FeederslCircuits -
Home — More than 30
To 2D0 A (a� $6 Each
(Specify)
�
Fee Calculation
F�cisting Home/Strvcture Remodel or Addifion
New Sen►icelPowar Supply D— 400 ampere d(,i $35
N�va 5ervic�Jf�ow�er SvPPIy - #81 — BBB ampere � $60 - ' _
New FeederslCircuits — Up to 15 Feeders/Circuits �
100 FeedersJCirc�its $6 Each or 16 to 30 $10D
idew Feeders/Circuits - More Than 30 Feeders/Cira�its
( ) FeedersJC'vcuits Up to 200 A(� $6 Each
Detached Garage dr Other Associated Structure
Nevr Service/Power Supply 0— 400 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
Other
Detached Garage or Other Associated Structure
New Servic�/Power Supply 0— 400 ampere @$35
New FeederslCircx�its
Reconnected Feeders/Circuits
Other (Specify) .
( ) @ $6 Eac�
( ) @ $2 Each
Tot'al (the fee calculated above or $35 multipiied Total (ihe fee cala�lated above or $35 muttiplied ���
by the number of required inspection trips, , by ihe number of required inspection trips,
whichever is greater) whichever is greater) .
Requests for Electrical Inspec8on (REq with a fee of $250 or less ezpire 12 morrths from the filing date. The owner must have the work completed withfn the
12 morrth period or submft another REI ihat inciudes the inspe�8on fee for the uncompleted work. InspecUon fees do not carry over from one REI to another.
A service cha e of $30 wiit be added for all dishonored ch�ks.
I hereby certiiy fhat I inspeded the eleatrical insta0ation herein on the dates stated: For Department Use Only
Rough — In Inspection(s) � Date ����x� s' �� �l� U r� R�� �o�v
�1- - ��`°�
Finallnspection � �, Date . �
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This material can be made avai(able in different forms, such as large
TDD (6�1j 297-4198.
REI 01 (6/07)
Braille or on a tape. To request,
Voice or