HomeMy WebLinkAboutElectrical Permit 12. 008 j\ kk \\p\V) 14\% /\() 11() Reset Form I Print Form
F or Office Use Only
Amount of Check: -Cheer Numb PermitTRAK Number:
ESOT � / /,
tvttld T tafx)f tiT F c` �%5
0
ELE G' v
f Ng* ■ s - $'c INDUSTRY
Aft
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. 11/18/2011
* Check One Box: 15 Contractor or ❑ Homeowner * Check One Box: ❑ New Bldg or El Existing Bldg
* Check One Box: 2 One - 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)
* Project Location (number & street name) * Project County
5512 v vuuuside ISOau SL
JI..V l l
* Project Township: (Please enter only the township name * Project City: * Project Zip
or the city name, not both) Prior Lake 55372
* Owner Name * Owner Phone Owner Cell Owner E -mail
Eugene Anderson None
* Company Type (check one box)
2 Electrical Contractor ❑ Technology System Contractor
* Company License Number * Company Name
CA06158 Mister Sparky
* Company Address * City * State * Zip Code
1904 Vermillion Street Hastings MN 55033
* Company Phone Company Cell * Company E -mail Contact Person and Phone Number
(651) 437 -4177 Tiffany Gorman 651 -437 -4177
* 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) IP Ready Now or ❑ Yes or 1151 No
❑ Will Schedule
Directions to Project Site
Wiring of AC Project Site (Contact Person and Phone Number)
Electrical Utility
TOTAL INSPECTION FEE from REI fee worksheet, or $35 multiplied Enter Inspection Fee Here» * 35
b the number of re • uired ins • ection tri • s, whichever is • reater.
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) 40
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 RD forms together itl' the applicable fees to:
MN Dept Labor & industry, PO Box 64227, St, Paul, MN 55164-0227
REI 10 (4/11) REI_10_OneAndTwoFamily.doc (Revised 4/1/11)