P - 76962Minnesota De
443 Lafayette
St. Paul, MN
Phone: (651
TTY/MRS:
www.ele '1
Co ac
Date
Q�18/o '7
f of Labor and Industry
North
1) 297-4188
.state.mn.us
:or Re uest for Electrical Ins
Rough-In lnspection Required?
C�ntractor Must Schedule All Rou h-In
�ection - Street
Owner Name
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Owner Tefephone Number(s) — Inc
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Contractor Name
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Contractor Telephone Number
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Contractor Authorized Signature
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RESIDENTIAL ELECTRICAL PERMIT BY CONTRA.CTOR
PERMIT# .��l�r�� fSI`%�C
RECEIVED: DCf`�11 C� D 1 0�nm
tion — One Famil Dweltin /Associated Struciure �
Yes Single Inspection Other Than Rough-In: � Ready Now
�ciions Contractor Must Schedule All Firtal Ins ctions Will Schedule •.
CitylTownship County
, l D LC-Y � .
Projed Description
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AreaCode(s) ��7g�` �A""'D4Y c�,2cyrT oL /�,�rsa Sa��62 CiRcti�r,
Contractor Maifing Address
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Contractor E-mail Address Electrical U6fity
mtractor License Number
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Fee Calculation
New Home or Associated Structure
New Dweliing Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — BDD ampere @$60
New Dwelling Feeders/Circuits
Up to 30 Feeders/C+rcurts -
New Home — More than 30 Keeders/Circuits (m add�tion to
�r,,,.,o� r 1 Feeriers/Circuits U� To 200 A CrD $6 Ea
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 4�0 ampere �$35
New Feeders/Circuits ( ) @ $6 Each
XC.�P
Job/Project Contact Person
T�'Y /'a C-3 cyF �
Existing Home/Structure Remodel or Addition
00
New Service/Power Supply �bo �0 =400 ampere � $35 '�j � —
New ServicelPower Supply 401 - 800 ampere �$60
New Feeders/Civcuits - Up to 15 FeederslCircuits fQ aa
3 FeederslCircuits $6 Each or 16 to 30 $100 / �
New Feeders/Circuits - More Than 30 FeederslCircuits
Feeders/Circuits U to 200 A $6 Each
Reconnected Feeders/Circuits Y pp
/Z Feeders/Circuits $2 Each 2'
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits
Reconne6ted Feeders/Circuits
Other (Specify)
( ) @ $6 Each
( ) � $2 Each
Total (the fee calculated above or $35 multiplied TOtal (the fee calculated above or $35 multiplied ��, Q�
by the number of required inspection trips, by the number of required inspection trips, �—a
whichever is greater) whichever is greater)
Requests for Electrical Inspection (REI) with a fee of SZ50 or less expire 12 months from the filing date. The contractor must have the work completed within
the 12 month period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of i30 will be added for all dishonored checks. ���,,��
I hereby certify that I inspected the electrical instaltation herein on fhe dates stated: For Department Use Onfy
Rough — In Inspection(s) Date
This m erial an e made a ailabl m ifferent forms, such as large print, Breille or on a tape. To request, call 1-800-342-5354 (DIAL-DU) Vo�ce or
TDD (651� 297-4198.
REI 02 (6/07)