P - 75580Minnesota Depa ,'� nt of Lab�r and Indusfry
443 Lafayette R' d North
Sti Paul, MN 5 55-4342
Phone: (651) 5D64
TTY/MRS: ( 1 } 297-4198
www.ele�tri .state.mn.us
RESIDENTIAL ELECTRICAL PERRAIT BY HOMEOWNER
PERMIT # � � �' � `°' � i � � �
RECENED: �- � ' �' �
Horrreowr�er Re ues�E for Electricaf Ins ectio�n
Date Rough-fn Inspecti�n Required? Yes ��P�� �erThan Rough-fn: Ready Pfova
�- a� o g Hameowner Must Schedule All Rou h-Ih Ins ec[ions Homeowner Must Scttedule All Final Ins ciions ❑ V�IiU 5chedule
Address of Ins�ion - Street Cit�+/Towmship Courity
,�� `7��f,i�soh Jlvd, /(/� �r��/P ''�y! o%Q
Owmer Name Project Description
.1oG�h G�-F1�PV /PPpIt.�G� e�ec7`�'i«.� r�asf o�',��ef����k
Owmer Telephone Numb�r�s) - lnciude Area Code(s) �Pp�a t� ���� � P� d o'�` •
763 -a�3-3���
Orwner Ma►Ting Address - 5treet Cdy State Zip Code
���o sf;h��� .���� ti_r- �,��°�'/� �ti ��s�3�
Owner E-mail Addr�ss Electrical Utifity
JoG�na �a� G�y�.G.��- �o� �CGe I �k� f °-- -�G'-c�
By signirtg this daa�ment, i c�rtify that I am the ovmer as defined by Minn. Stat § 326.01 and wnll legally pertorm the electricai vwrk
Owner 5ign,�ture
_ i� •
Fee Calculation
New Home or Associated Strucivre Exist�ng Home/Strvcture Remodel or Addiiion
tSew Home Service/Power Supply 0- 400 ampere @$35 New ServicelPauver Su� o� 0- 400 ampere �$35
New Home SenricelPower SuPPN 401 - 800 amPere @ S6U We�nr 5erviceiPouvzr SuPPIy 40t- 8DD ampeFe a�--$69 --
New Hame Feeders/Circx�its New F�eders/Circuits - Up to 15 Fe�erslCircuits
New Home - More than 30
K?]
To 20d A
'cuits - $100 �
tion to �le�
Each
Detached Garege or Ofiher Associated Structure
New SenricPJPower Supply 0- 400 ampere @$35
New Feeders/Circuits
Ott�er (S�cify)
Otfier
( j @ $6 Each
16tc30(D�10D
- More Than 30
3�
( ) FeederslCircuits @ $2 Each �
Detached Garage or Otber Associated Structure
Nevv ServicelPower Supply 0- 4U0 ampere @$35
New FeederslC'rcc�its
Reconnected FeederslCircuiEs
Other (Specify) .
( ) @ $6 Eac�
i ) @ $2 Each
0
Total (the fee ca{culated above or $35 muftiplied Total (fhe fee caicwlated above or $35 muttiplied
by the number of required inspedion trips, , by the number of required inspection trips, I a�
whichever is greater) rrohichever � greater) �
Request�for Electrical Inspection (REI) v,�th a f� of �250 or less ezpire 12 morrths from the filing date. The owner must have the work completed wfthfn �
12 mo ri
I hereb at 1 h
Rough - In Inspec
G
Final Inspection
This materSal can i
TDD (651) 29T-4198.
REI 01 (6/07)
inciudes the i�pectlon fee for the uncompleted work. Inspectlon fees do not carry over from one REI er. `
A service e of $30 vviil 6e added for aIl dishonored checks. ��
la(lation herein on Uie dates stated: For Depa e t Use Only `
Date - �� � �� �►-�G"
t</P� - � _ C�� � "` 00`�� �!%��
��� C'D S E P�0 2 200�
� ���
different forms, such as large print, Braflle or a tape. To request,
Voice or