P - 75223Nfinnesota De�-�rtment of Labor and Industry RESIDENTI ELECTRICAL PERMIT BY HOMEOWNER
443 Lafayett � �ad North �
Sti Paul, MN, 5155-4342 PERMIT # " ' �� � 'a � �
Phone: (65 284-5D64 REC��� Q � �
TTY/MRS: 51) 297-4198 .
www.e .state.mn.us
Homeowner Re uest for Electrical Ins ectib�n
Date Rough-In Inspedion Required? ❑ Yes Inspec�ion OtherThan Rough-ln: � Ready Nov�
� a� Home�wmer Must Schedule All Rou h-Ih Ins ections Homecwner Must Schedule All Final Ins ctions ❑ V�iU 5chedule
Add of InspecEion - Street City� ship County
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er Name Projed Description
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Owner Telephone Numise s) - Include Area Code(s) .
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Owmer Maiting Address - Stree City�, State Zip Code
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Owner E-mail Address Elecirical Utifity
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By ' ning this docUment, I riify fhat 1 am the owner as defined by Minn. Stat § 326.01 and will legally pertorm the eledrical work
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�� �J � Fee Ca{culation
New Home or Associated Structure Existing Home/Strvctur Remod or Addi�ian
New Home Servic$/Pawer Supply 0— 400 ampere @$35 New Senrice/Power Supply �— 400 ampere @$35
New Home Senrice/Power Suppiy 401 — 800 ampere �$6D New Service/Powrer Supply 401 — 8DD ampere @$6D
New Home Feeders/Circxiits New Feeders/Circuits — Up to 15 Feeders/Circuits
U to 30 FeedersJCircuits -$100 FeederslCires��s $6 Each or 16 to 30 $10D
Nevv Home — More than 30 FeederslCira��its (in addition to ?Jew Feeders/Ch�cuits - More Than 30 Feeders/Circwits
above) ( ) FeedersJCircuits Up To 200 A(� $6 Eacb ( ) Feeders/Circuits Up to 200 A C� $6 Each
Detached Garage dr Other Associated Structure
New ServicelPower Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each
( L ) FeedersJCircuits @ $2 Each �
Detached Garage or Oiher Associated Strvcture
New Service/Power Supply 0— 400 ampere @$35
New Feeders/Circuits ( ) @ $6 Each �
Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) Other (5pecify) .
Total (the fee calculated above or $35 multiplied Totitl (ihe fee calculated above or $35 muttiplied
by the number of required inspection trips, , by the number of required inspaction trips, 1��
whichever is greater) whichever is greater) �a
Requests for Electrical InspecUon (REI) with a fee of $250 or less expire 12 monUis from the filing date. The owner must have the work completed within the
12 month period or submit another REI that includes the Inspecfion fee for the uncompleted work. Inspeetion fees do not carry over from one REI to another.
A servlce cha e of $30 will be added for aIl dishonored checks.
I hereby �rtify fhat I inspeGed the el�trical i�Ilation herein on the dates stated: For Department Use Only
Rough - In Inspecfio Date
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Finallnspection Date .
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This material can be made available in different forms, s ch as large print, Braille or on a tape. To request, call 1-8�0-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.
REI 01 (6/0�