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P - 75711�_ _ z Minnesota Dep , nt of Labor and Industry 443 Lafayette: ad North Sti Paul, MN' S155-4342 Phone: (6 � 284-5064 TTYIMR (651) 297-41�8 ,�"�c � Address of I� '�3'��' VNZ Owner Nam� °4'iV� Ovmer Tele� �( („?, _ Owner �By s this Homeowner Rough-In Inspection Required? Homeowmer Must Schedule All Rc inn _ GtrnPt est for Electrical I � Y� Inspection Other l �� - ��97 REC'D AU G 16 2001 Schedule All V�� W�� Oi/ l'�1 I �'� �.�v� i t, I c�ttify that I am the owner as defined by Minn. Stat § 326.01 and w�ll 4' New Home or Associated Structure New Home Service/Power Supply 0— 400 ampere �$35 New Home SenricelPower Suppy 401 — 800 ampere @$60 New Home Feeders/Circuits Ready No� V1rll Sct►edule State the electrical work Fee Calculation Existing Home/Structure Remodel or Addition New Senric�/Povuer Supply 0— 400 ampere �$35 New Service/Power Suppiy 401 — B00 ampere �$60 Nww FaadarslCirr�iffc — I ln tn 15 FEwrlPrclGim�irtc Up to 30 Feeders/Circuits - $100 New Home — More than 30 Feeders/Circuits (in addftion to above) ( ) Feeders/Circuits Up To 200 A@$6 Each Other (Specify) Detached Garage or Other Associated Structure New Servic�/Power Supply 0— 4Q0 ampere @$35 New Feeders/G'trcuits ( ) � $6 Each Other (Specify) Other (Specify) Feeders/Circuits $6 Eact� or 16 to 30 $100 Neuv Feeder�Circuits — More Than 30 Feeders/Circxiits rcx Feeders/Cira�its U to 200 A $6 Each Reconnected Feeders/Circ�its Feeders/Circuits $2 Each Detached Garage or Other Associated Structure New Service/Power Supply 0— 400 ampere �$35 New FeederslCir its /�G,�' ( � ) @ $6 Each D !O Reconneded Feeders/Circuits ( ) @ $2 E�ch Other (Specify) . � �� Total (the fee calculated above or $35 mu(tlplied Total (the fee calculated above or $35 multipiied by the number of required inspedion trips, , by the number of required inspection trips, whichever is greater) whichever is greater) Requests for Electrical Ins�on (REI) with a fee of $250 or less expire 12 motrths from the fliing date. The owner must have the work completed wffhin the 12 month period or subm(t another itEl that includes the i�peetlon tee for the uncompleted work Inspection fees do not carry over from one REI to another. A seroice e e of $30 will be added for aq dishanored checks. I hereby c�Nfy fhat I inspected the electrical fistallation herein on the dates stated: For Departmen! Use Onty Rough — In Inspection(s} Date This material can be made avatlable in dffferent fom�s, sueh as large print, Brallle or on a TDD (651) 29T-4198. REI 01 (6/07) or � - � R � ��_� �a � - ��: s.s�-a'+" • , FRIDLEY MiJNICIPAL CENTER • 6431 UTTIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287 BUILDING PERMIT APPLICANT: PROPERTY OWNER I, � �� Y�/ understand that the State of Minnesota requires th t all residential building contractors, remodelers and roofers obtain a state license unless they qualify for a specific exemption from the licensing requirements. As the owner of the property at ��I�- VtilP/mtito�nA I,�n (�� , Fridley, I am exempt from the state licensing requirem nt only if I am not building or improving this property for purposes of resale. By signing this document, I attest to the fact that I am improving this house for my own use and do not intend to sell it. I hereby claim to be exempt from the state licensing requirements because I am not in the business of building or remodeling on speculation or for resale and that the house for which I am applying for this permit, isl th� _first residential structure I have built or improved in the past 24 months. I also acknowfedge that because I do not have a state license, I forFeit any mechanic's lien rights to which I may otherwiise have been entitled under Minn. Stat. 514.01. Furthermore, I acknowledge that I may be hiring independent contractors to perform certain aspects of the construction or improvement of this house and I understand that some of these contractors may be required to be licensed by the State of Minnesota. I understand that unlicensed residential contracting, remodeling, and/or roofing activity is a misdemeanor under Minnesota law, and that I would forfeit my rights to reimbursement from the Contractor's Recovery Fund in the event that any contractors I hire are unlicensed. I have also been informed and acknowledge that by listing myself as the contractor for this project, I alone will be responsible to the City of Fridley for compliance with all applicable building codes and city ordinances in connection with the work being pecFormed on this property. Name � � Date 8 "�(a -0 %