P - 75289Minnesota Departrnent of Labor and Industry RESIDENTIAL ELECTRICAL PERMIT BY CONTRA.CTOR
443 Lafayette Road North PERMIT # ��
St Paul, MN 551 �5-4342
Phone: (651) 5064 RECENED:
TTYRJIRS: (6 - ) 297-41 S8
vdww.eledri .state.mn.us
Contr tor Re uest for Electrical Ins ection — One Famil Dweliin lAssociated Structure
Date ° Rough-In Inspedion Required? /j/� ❑ Yes Single Inspeciion Other Than Rough-In: � Ready Now
O`—���� U Contractor Must Schedule All Rou h-In Ins eciions Contractor Must Schedule All Final Ins ciions Will Schedule
Address of Inspec�ion — Street Citylfownship C�unty
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Owmer Name Projed Descxiption
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Owner Teiephone Number(s) — Inciude Area Code(s) 7�D v2TJD A-/►�� �Q ,%� .�D�' l� OQC�
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C�ntractnr Name Contrador Mailing Address
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Contractor Telephone Number Contractor E-mail Address E cfi�l Util'ity
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ntra r Au4hor¢ed Signature Contractor Lic�nse Number • Job/Projec� Contaat Person
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� Fee Calcutation
New Home or Assoc{ated Structure Existing Home/SEructure Remodel or Addition
. Plew Dwelfing Service/Power Suppy �— 400 ampere �$35 New Service/Power Suppiv� __ 0— 4Q0 ampere �$35 ���
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New Dwel(ing Senrice/Power Suppiy 401 — 800 ampere @$60 New Senrice/Power Suppfy 401— 8D0 ampere �$60
- --
New Dwelling Feeders/Circuits New FeederslCi►atf� — Up to-t5 F-eede�-irouits-- - -- -
U to 30 FeederslCira�its -$10D Feeders/Cira�its $fi Each or 16 to 30 $10�
Plew Home — More than 30 �eeders/Circuits (in addition to New FeedersJCircuits — More Than 30 Feeders/Circuits
above Feeders/Circuits U To 200 A $6 Each FeederslCircuits U to 200 A $6 Each
Other (Specify) Reconneded FeederslCircuits ��
Feeders/Circuits $2 Eacfi �� �
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Service/Power Supply 0— 4U0 ampere @$35 New Service/Power Supply 0— 400 ampere @$35
New FeederslCircuits ( ) � $6 Each New Feeders/Circuits ( ) @ $6 Each
Other (Specify) Reconnested Feeders/Circuits ( ) � $2 Eac�
Other (Speafy) Other (Speay) --
Tot31(the fee calculated above or $35 multiplied Total (the fee cxiculated above or $35 multiplied �"y'
by the number of required inspecNon trips, by the numtrer of required inspection trips, C� �
whichever is greater) whichever is greater) �Q l
Requests for Electri�l Inspection (REI) with a iee of $250 or less expire 12 months from the ftling date.l'he co�actor must have the wa-k completed wfthin
the 12 month pEriod or submk another REI that includes the ins�on fee for the unaompleted work. l�pection fees do not carry over from one REI to
another.
A service charge of $30 wfll be added for all dishonored checks.
I hereby certify that I inspeded the electrical instailation herein on the dates stated: For Depar6nent Use Only
Rough — In Inspection(s) Date � �G� _ �`� � � � � h � _• 20��
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Final Inspeciio ' _� Date �
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T6is materia can be m de tlable in different forms, uch as large print, Braille or on a tape. To request, call 7-Sd0-342-5 (DIAL-DLt) Vofce or
TDD (651j 297-4196.
RE102 (6/07)