P - 75319. �
, .
Minnesota De
443 Lafayette
Sti Paul, MN .
Phone: (65
TTY/MRS:
www.ele
.,
a nt of Labor and Industry
d N�rth
155-4342
!84-5DG4
1) 297-4198 ,
.state_mn.us
�" Homeowner
Date Rough-In lnspection Required?
Homeovmer Must Schedule All Rc
Address of fnspection - Street
/G� i��r��,��.� c,�;����
Owner Name /
� c✓�f � �t� .e�° � a
O�rner Telephane Number(s) - inGude Area Code(s)
�� 3 - 5 7,� - �c��C, � / � -7/ - �i � i�
ilumor Mnilinn �I�f�r�aRC — S+TP_P_t
lii'��.a!
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT # ��� � �� �JS�'
RECENED: QG'i`Nl Alfl —
uest for Electrical Ins eciib�n
� y� Inspection Ofher Than Rough-In:
Insoections Homeowner Must Schedule All Fnal
f=P; � C�
Project Des
�c�'� ��.-���
C��°�` � L, ,� �
Ready Nov�
v�u s�t,edu
�,
c�a ""�'�'�c`h
�
Owner E-mail Address I t�ecuiCa� uuiay
�h c'.z.(
By signing this dacument, I c�rfify that I am the ovmer as defined by Minn. Stat § 326.01 and wnll legally pertorm the electrical vwrk
Oamer Signature
s.�a G,�-1 /�—� � • -
Fee Caiculation
New Home or AssQCiaied Structure
New Hortre SenriceJPower Supply 0- 400 ampere @$35
iJew-tfome Senr'rce/Power SuPPN 43'L -.80Q aruPere @$fiD
New Home FeedersJCircuits
Up to 30 FeederslCircuits - $100
tlew Home - More fhan 30 Feeders/Circuits (in add�ion to
above) ( ) Feeders/Circuits Up To 2D0 A@$6 Each
Other (SpecifY)
Detached Garage or Other Associated Structure
Idear ServicelPower Supply
New FeedersJCirzuits
0 - 400 ampere @ $35
( ) @ $6 Each
Existing Home/Strvcture Remodel or Addi�ion
New Servirz/Power Supply
New SenricdPoarer &�pply
New Feeders/Cirauiis - Up to 15
( ) FeedersJCiraiits @ $1
i�lew FeederslCircui� - M�re Th
( ) Feeders/Circuits
RecorineaYed FeederslCircuits
0 - 400 ampere @ $35
-0�U1 - 896 emper� � $6Q- - _ �- --
.�,....K�
30 Feeders/Circ��its
to 200 A (v� $6 Each
( ) FeederslCircuits @ $2 Each �
Detached Garage or OYher Associated Structure
Newr Service/Power Suppiy
New Feeders/Circ�its
Reconnected Feedets/Circu'�ts
Other (SpecHY)S� .
0 - 400 ampere @ $35
( )@$6Each
( ) @ $2 Each
To�l (the fee calculated above or $35 muftiplied Total (ihe fee calculated above r$35 muttiplied
by the number of requfred inspection trips, , by the number of required insp 'on trips, !�%�� �^,
whichever is greater) whichever is greater) �(f ✓(/
Requests for Electrical Inspection (REI) with a fee of $250 or less ezpire 12 morrths from the filfng date. The wner must have the work completed withfn the
12 month period or submft another I2EI that f�ludes the irtspectlon fee for the uncompleted work. Inspectl fees do not carry over from one REI to another.
A servlce e of $30 wtli be added for aD dishonored ch ks.
I hereby �rdfy fhat I inspederl the etectrical installatfan herein on the dates �ate�: or Department Use Only
Rough-�I ,p o�n(s)" - /�-/o1Za,� �
! /_ ;"'��/ �-/.A. — rC/A _ %Z` 1 �
Final [�ispection Date ,�/
,w=—_ 6� ' S = � �T
This material can be made available in d'�fferent forms, such as large prii
TDD (651) 297�196.
RE101 (6/On
or on a hpe. To request,
or