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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