HomeMy WebLinkAboutElectrical Permit 12. 046 Reset Form Print Form
For Office Use Only
Amount of Check: Check Number: /� PermitTRAK Number:
MINNESOTA DEPARTMENT OF /? CA.) / C)U / ' ELE / Z — — (/
1 LABOR & INDUSTRY
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443 Lafayette Road North Request for Electrical Inspection (REI) (permit)
St. Paul, MN 55155 -4342
Phone: (651) 284 -5026 Non - Dwellings and Multi- Family Dwellings
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. / 0 — / 2_
* Check One: ,Contractor or ❑ Registered Employer * Check One Box: ❑ New Bldg or ❑ Existing Bldg
t
* Check One Box: ❑ Multi - Family Dwelling or ►:4 Non - Dwelling (all projects other than dwellings)
* Permit Sub -Type (check one box)
❑ Agricultural aRt,Commercial ❑ Government ❑ Industrial ❑ Institutional ❑ Recreational ❑ Technology
* Project Location (num er & street nam * Project County
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* Project Township: (Please enter only the township name * Pro ect City: * Project Zip
or the city name, not both) nor r L 0, c- e_
* Owner Na * Owner Phone Owner Cell Owner E -mail
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* Company Type (check one box)
Electrical Contractor ❑ Technology System Contractor ❑ Registered Employer ❑ Class B Installer
* Company License /Registration No. * Company Name
E. IN 000 `\ 5(0 d 1 n , .S>,lr-- b►tiS U L
* Company Addr�s I � ` A/ � * City � ( cl � * State * Zip Code
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* Company Phone Company Cell ` * Company E -mail Contact Person a� Number
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* 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 Now or I �
I (will Schedule ❑ Yes or ►. No
��"e'ra -4� V(.)\ctc. LR .� Directions to Project Site
a+ SGt ►ti -d. Vol I `A— Bea c,L Project Site (Contact Person and Phone)
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G Electrical Utility
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TOTAL INSPECTION FEE from REI fee worksheet, or $35 multiplied Enter Inspection Fee Here » * / �� —
by the number of required inspection trips, whichever is greater.
A surcharge of $5 is imposed on every permit effective 7/1/10 Surcharge Fee» $ 5.00
as per M.S. § 326B.148, in addition to the inspection fee.
* Grand Total (Inspection Fee plus Surcharge Fee) * / Lo —
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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 TDD (651) 297 -4198.
Please submit REI forms together with the applicable fees to:
MN Dept Labor & Industry, PO Box 64227, St. Paul, MN 55164 -0227
REI 11 (4/11) REI_11 _MultiFamilyAndNonDwellings.doc (Revised 4/1/11)