P - 75535Minnesota Depart�efit of Labor and Industry
443 Lafayette Rofl�N�rth
Sti Paul, MN 5 'S5-4342
Phone: (651), �4-5D64
TTY/MRS: 1) 297-4198
wv�na.ele ' .state.mn.us
Homeawner
Date Rough-In Inspection Required?
�. ' I L- � Homeowner Must Schedule All Ro
Add of Insp�n - Street �� ��
Owner Name � lr' �� '�' • ` ��
��p� � �y
�wner ele ne Number(s) - Include� a Cade(s)
`� �n�� �'�'I _ �.,�'l � rii ��1i.,h, l �i�i�
Owner E-mail Address
By signirtg this u nt, I
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT #
RECENED:
:sf for Electrical Ins ectib�n
y� Inspectiqn OtherThan Rough-In: Ready Nov�
�ections Homeowner Must Schedule All Fnal lnsoections II 5chedule
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�►ry ^ ' I 'v • �tate up �
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Ele 'cal UhT
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owner as defined by Minn. Stat § 326.01 and will leg y rm the electrical work
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Fee Calculation �
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home Service/Power 5uppfy 0- 4UD ampere �$35 �� New Senrtce/Pouver Supply 0- 400 ampere @$35
New Home Senrice/Power Suppy 401 - 800 ampere @�60 Nevu Senric�/Power Supply 401 - 800 arnpere @�60
New Home Feeders/Circuits New Feeders/Circuits - Up to 15 Feeciers/Circwits
U to 3D FeedersJCircuits -$100 `� FeedersJCircuits $6 Each or 16 to 30 $10D
New Home - More than 30 FeedersJCira�its ('in add'�rion to iJew Feeders/Circuits - More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each Feeders/Circvits U to 20D A $6 Each
Other (Specify) Recorineated Feedars✓Cirauitis
' • FeederslCircuits $2 Each
Detached Garage or Other Associated SfiruCture Detached Garage or Oiher Associated Structure
New Service/Power Supply 0- 400 ampere @$35 New 5ervice/Power Supply 0- 400 ampere @�35
New Feeders/Circuits ( ) @ $6 Each New Feeders/Cira�its ( ) @ $6 Each �
Other (Specify) Reconnected Feeders/Circuifs ( ) � $2 Each
To%al (the fee calcutated above or $35 multiplied Total (the fee calculated above or $35 muttiplied �'
by the numtrer of required inspedion trips, , by ihe number of required inspection trips, . ��� `
whichever is greater) whichever is greater) .
�
Requests for Eleclrl�al Inspec8on (REI) with a fee of $250 or less ezpfre 12 mo►rths from the fil g date. The owner must have the work completed within the
12 morrth pe�iod or submft another REI ihat inciudes the irtspeetion fee for the uncompleted ork InspeeUon fees do not carry over from one REI to another.
is T A servica ch e of $30 wiil6e added for a0 - �shonored cnecks.
I hereby certlfy fhat I tnspeded the electrical instaltafion herein on the dates stated: For Departrt►ent Use Oniy
Rough - In Inspedion s'. ate �� �
`� - D � �
Final lnspedion Dat . •
� � �` RE�'p MAY 13 2008
This materfal can b de available in different forms, such as large p Braille or on a tape. To request, call 1-B00-342-53:
TDD (651) 297-4198.
REI 01 (6/07}
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