HomeMy WebLinkAboutElectrical Permit 12. 0139 c)\______� Reset Form 1 Print Form
For Office Use Only
Amount of Check: .0 sit Number: C PermitT4 $I Number: L
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MINNESOTA DEPARTMENT OF f�C i %> 7t�C ELE /L— /3 f
r L ABOR & INDUSTRY
Request for Electrical Inspection (REI) (permit)
443 Lafayette Road North
St. Paul, MN 55155 -4342 One and Two - Family Dwellings
Phone: (651) 284 - 5026
www.dli.mn.gov
Fields marked with an asterisk * are required (as applicable). * TODAY'S DATE
Incomplete, inaccurate, or illegible forms may be returned to the submitter. 1-112(01i2-_.
* Check One Box: XContractor or ❑ Homeowner * Check One Box: ❑ New Bldg or ,k'xisting Bldg
* Check One Box: ne- Family Dwelling (homeowner or contractor) OR ❑ Two - Family Dwelling (contractors only)
(It is unlawful for homeowners to perform electrical work on property that is rented, leased or occupied by others)
* P. r go j ect Lo ^.lion (number & street name * roject C unty
kWh/51 �1 eC •
* Project Township: (Please enter only the township name * olect City: * Pre Zip
or the city name, not both) oQ 66
* et ner Nam- *0 ner Pho e Owner Cell Owner E -mail
•
■ t (L ttb & &�� / 4 �
:g mpany pe (check one box)
Electrical Contractor ❑ Technology System Contractor
* C m License Number * Company Name [ ��
e . any \I- -- V' e, � 1,e.ek�c.,
* Company Address * Ity * State * Zip Code
a°1 ?,1 � ..Ave, S ,c�m
1t \roan MN 55 12-(
* Com any Ph e Company Cell * Comp ny E -mail ! Contact Person and Phone Number
* Project Description (Scope of work, service size, quantity of Single Inspection "Rough-in Inspection
feeders and circuits, job numbers, or other vital information to Other than Rough -in? Required?
help the electrical inspector make timely inspection service) Ready P P Y P ) ❑ Read Now or
Yes or El No
g� � , Q `nom WI ill Schedule
��` v�X-^ Directions to Project Site
Project Site (Contact Person and Phone Number)
Electrical Utility
TOTAL INSPECTION FEE from REI fee worksheet, or $35 multi Enter Inspection Fee Here» * 70 .-----
by the number of required inspection trips, whichever is greater.
A surcharge of $5 is imposed on every permit effective 711110 Surcharge Fee » $ 5.00
as per M.S. § 326B.148, in addition to the inspection fee.
,, * Grand Total (Inspection Fee plus Surcharge Fee) 6-
Requests for Electrical Inspection (REI) with a fee of $250 or less expire 12 months from the filing date. The installer must have the work completed within the 12 month
period or submit another REI that includes the inspection fee for the uncompleted work. Inspection fees do not carry over from an expired REI to a new REI.
A service charge of $30 will be added for all dishonored checks.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1 -800- 342 -5354 (DIAL -DLI) Voice or TOD (651) 297 -4198.
Please submit REI forms together with the applicable fees to:
MN Dept Labor & Industry, PO Box 64218, St, Paul, MN 55164 -0218
REI 10 (4/11) REI_10_OneAndTwoFamily.doc (Revised 4/1/11)