HomeMy WebLinkAboutElectrical Permit 12. 175 p
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ate Rough-In Inspection Required? � Yes Inspection Other Than Rough-in : Q Ready Now
Homeowner Must Schedule All Rough-In Inspections Homeowner Must Schedule All Final Inspections ill Schedule
(owner
ddress of Inspection — treet / Project Description :
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Owner Name
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Owner Phone
Home : Cell: 7 �Z " ZgQ ' �{ � Q S
Mailing Address (if different from above) Electrical Utility
By signing this document, I certify that I am the owner as defined by Minn. Stat. 325 .01 and will legally perform the electrical work.
Owner Signature
FEE dDMCULATION
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home Service/Power Supply 0-400 ampere @ $35 New Home Service/Power Supply 0-400 ampere @$35
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New Home Service 401 - 800 ampere @ $60 New Service/Power Supply 401 -800 ampere @ $60
New Home Feeders/Circuits New/Extended Feeders/Circuits Up to 15 Feeders /Circuits ( )
Up to 30 Feeders/circuits $100 Feeders/Circuits @ $6 Each or 16 to 30
New Home - More than 30 Feeders/Circuits (in addition to above New/Extended Feeders/Circuits - More than 30 Feeders/
( ) Feeders/Circuits up to 200A @ $6 Each Circuits ( ) Feeders/Circuits Up to 200 A @ $6 Each
Other (Specify) Reconnected Feeders/Circuits ( ) @ $2 Each
Manufactured Home Park Lot Supply ( ) $35 Each Special Inspection Fee ( ) Hours @ $80 Per Hour
Plus f Miles @AThe IRS Milooge Rate of
Detached Garage or Other Associated Structure Detached Oarage or O heeAssssociated Structure
New Home Service/Power Supply 0-400 ampere @$35 New Home Service/Power Supply 0400 ampere @ $ 35
New Feeders/Circuits ( ) @ $6 Each New/Extended Feeders/Circuits ( ) @ $6 Each
Other (Specify) Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) n G L�o 5 _ State Surcharge = $5.00 C'
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TOTAL (the fee calculated above or $35 multiplied by the TOTAL (the fee calculated above or $35 multiplied by the
number of required inspection trips, whichever is eater) number of required inspection trips, whichever is greater) —
� � Receipt # 4&049
Requests for Electrical Inspection (REI) with a fee of $ 250 or less expire 12 months from the filing date. The owner
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 one REI to another. A service charge of $ 28 will be
added for all dishonored checks .
I hereby certify that I inspected the electrical installation herein on the
dates stated:
Rough4n Inspection (s) Date Walt l.usian , Electrical Inspector
952 . 934 . 0229
Final Inspection Date
WALT LUSIAN
IAEI Certified
Master Electrical Inspector
MINNESOTA DEPARTMENT OF
,AI OR INDUSTRY
16275 Sheldon Ave.
Eden Prairie, W 55344 Office Hours 7:00-8:30 a.m.
Tel . (952) 934-0229 Mon :Fri.
Order for Payment
Date Request for Inspection Serial Number Date Filed
Electrical Contractor/Installer License Number
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Owner/Occupant County
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Job Address - Street EYAownship
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This Order for Payment is for additional fees associated with the above referenced Request for Electrical Inspection .
Fee Calculation/Explanation
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Return this Order for Payment with your check payable to the a in the
amount of $ by ID (fourteen days from the date issued )
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A service charge of $30 will be added for all dishonored checks.
Inspector Name and Number For Department Use Only
Inspector Telephone Number
Ins a orb Email Add s/website
Inspector Signature