P - 75520Minnesota Depa nt of Labor and industry RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
443 Lafayette R ad North PERMIT #
Si Paul, MN 155-4342
Ph�ne: (651) 5D64 RECENED:
TTYIMRS: ( 1) 297-4198 ,
www.elec�ri .state.mn.us
Homeowner Re uest for Electricaf Ins ectib�n
Date Rough-In Inspecfiican Required? Yes ��P�an Other Than Rough-In: � Ready Wov�
�"" �`� Homeowner Must Scheduie All R�u h-Ih Ins ections Homeowner Must Schedule All Fnal lns 'ons ❑ V�il! Schedule
Address of Inspeetion — treet C' IToamship unty
C�C�L\CC� ��c.��s�N �S �� s��i ��
Name Projed Descaiption
l �G'�\� ���� ��C� S�iC�
Owner Telephane Number(s) — InGude Area Code(s) �� ,��� � l
�-? �� - �tl-Z- -��1 � �� .� �o��r ��� �;-�
Owmer Maling Address — 5treet C State Zip Code
�, � J �c��so,N �� , �� ����� � �M�1 5�'�
Owmer E-mail Address E�� ���
�S'�c�i��°�0���� C�\ r�L.
By signing this docu ent, I�' fhat i the owner as defined by Minn. Stat § 326.01 and wi►A legally perForm the electrical wark
Owmer 5ig ure .
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Fee Ca{culation
tdew Home or Associated Struciure Exisfing HomeJStructure Remodel or Addi�ion
New Fiome ServicelPovrer SWPIy �— 4U0 ampere @$35 New Sstvice/Power SuPPIy 0— 400 ampere @$35
New Hort� ServicetPower SuPPN 4Di -B66ampere ��60 New 5enric�lPo�erSuPPh' "d�01"= B60 ampere @$6D '
New Home FeederstCircvffs New FeederslCircuffs — Up to 15 FeederslCircuits
U to 3D FeederslCirev'rfs -$1 DO r e f` Feeders/Circuits $6 Each or 16 to 30 $1 DO
New Home — More than 3U FeederslCircuits ('in add�ion to �I w FeederslCircuits - Mare Than 30 Fe�ierslCiravits
..�..,....� r � G�A�irirn,�s 110 To 20D A!rD S5 Each Feeders/Circu'rfs U to 200 A $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere �$35
New Feeders/C'�rcuits ( ) @ $6 Each
( ) Feeders/Cirr.uits @ $2 Each �
Detached Garage or Other Associated Structure
New Servic�/Power Suppy 0— 400 ampere @$35
New Feeders/Circuits ( ) @ S�6 Eadi •
Reconnected FeederslCircuits ( ) @ $2 Each
Totdl (the fee cala�lated above or $35 muftiplied Totdl (the fee calcutated above or $35 muttiplied �,�
by the number of required inspedion trips, , by the number of requ�red inspection fips, �
whichever is greater) whichever is greater)
Requests for Electrical l�pectlon (REt) with a fee of $250 or less �pire 12 morths from the filing date. The owner must have the work compteted within
12 morrth perfod or submft another REI that inGudes the f�petUon fee for the uncompleted work. Inspection fees do not carty over from one REI to er.
A service char a of $30 wtii be added for atl dishonored checks. ��
� hereby ceNy fhat I inspeded the e��trical installati�n herefi on tl� dates shate�: For Departrnent Use Only
Rough — In Inspection(s) ' Date �� � � �
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Final Inspedion �� Mi1 S E P 1 6 ZOOQ
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This mate�ial can be ade avatlabte in different fo , sucfi as large print, Braflle or on a tape. To request, cafl 1-8d0-342-5354 (DIAL-DLI) Voice or
TDD (651) 29T-4196.
REI 01 (6/07)