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Niinnesota Departmen���abar and Industry ��r �� RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
443 Lafayette Road �rth �q •
Sti Paul, MN 55 F�4342 �� PERMIT # r�l� r� �� ��
Ph�ne: (651) �,'�asa RECENED: ,�rrm n �n Il� ��nnn
TTY/MRS: ( , ) 297-4198
wvrw.e .state.mn.us
Homeawner Re uest for Electricai Ins ectio�n
Date R�ugh-In Inspection Required? Yes ��P���n OfherThan Rough-In: ❑ Ready Nov�
Homeowner Must Schedule All Rou h-Ih Ins ections Homeawner Must Schedule Atl Fnal dns ctions ❑ N�II Schedule
Address of Inspecti�n — Street City/Tovmship County
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Owner Name Prn}ed Descripfion G��� ��`�'�/'`2��
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Owner i"elephone Nurnber(s) — include Area Cade(s) .
7�3 ��/ Qd?,s``% e�[-���,-. �.�.�.� ��
Owmer Maifing Address — Street Ciry State Zip Cade
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Owner E-mail Address . Eleclric�l U6fity
By signirtg this dacument, I c�rtify that I am tF►e owner as defined by Minn. Stat § 3Z6.01 and witl legaily perform the electrical work
Owner Signature •
Fee Ca{culation
New Home or Ass�ciated Struciure Existing HomelStructure Remodel or AddifSon
New Home ServiceJPav✓er Suppfy 0- 4U0 ampere �$35 New Senrice/Power Supply 0- 400 ampere @$35
New Home Service/Power Supply 401 - 800 ampere @$60 New �ervir.�/Power Suppiy -- 4D1 - 8�D arripere ��6D - -
New Home Feeders/Circuits New FeederslCircuiis - Up to 15 Feeders/Circuits
U to 30 FeedersJCircuifs -�100 FeedersJCir�uifs $8 Each or 16 to 30 $100
New Home - More than 30 Feeders/Circ:uits (in addiiion to idew Feeders/Circuits - More Than 30 FeedersJCircuits
above FeederslCircuits U To 200 A $6 Eacl� Feeders/Circuits U to 200 A $6 Each
Other (Specify) Resorin�ect�� ers/Cirai�-�� Z 4-
� �� Feeders/Circuits $2 Each
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Se►vice/Power Supply 0- 400 ampere @$35 New Service/Power Supply D- 400 ampere @$35
New Feeders/Cirwits ( ) @ $6 Each New FeederslCircx�its ( ) @ $fi Each �
Other (Specify)
Reconnected Feeders/Circu'�fs ( ) @ $2 Each
Tot�l (fhe fee calculated above or $35 muftiplied 7otal (fhe fee calcvlated above or $35 mu�iplied
by the number of required inspec6on trips, , by the number of required inspection trips, /� ef1
whichever is greater) whichever �s greater) U J�/
�
Requests for ElectrFcal Inspection (REI) with a fee of �250 or tess expire 12 morrths from the 81ing date. The owner must have the work compl d wfthin the
12 morrth period or submft another REI fhat f�Iudes the irtspectlen fee for the uncompleted work. Inspection fees do not carty over from one I to another.
A servlce cha e of $30 will be added for all dishonored ch2cks.
I hereby cert3fy fhat I Inspected the electrical installatlan herem on the dates stated: . For Departrnent Use Only
Rough — In Inspecti Date ,
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Finallnspection Date�y/ . �
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This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 'f-B00-342- (DIAL-DLI) Voice or
TDD (651) 29T-4196.
REI 01 (6/07) '