HomeMy WebLinkAboutElectrical Permit 12. 379 04 PRIp4�
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HOMEOWNER REQUEST FOR ELECTRICAL INSPECTION
Da t Rough-In Inspection Required ? Yes Inspection Other Than Rough-in : Ready Now
Q / Homeowner Must Schedule All Rough-In Inspections Homeowner Must Schedule All Final Inspections Will Schedule
Address of Inspection - Street p y� / QJ� ✓� Project Description:
Owner Name LQ 6-✓ t
Owner Phone
Home : Cell:
Owner Mailing Address (if different from above) Electrical Utility
By s' ng this_d ument, I cer ' that I am the owner as defined by Minn. Stat. 325 . 01 and will legally perform the electrical work.
Owner Signature
FEE CALCULATION
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
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/
O Feeders/Circuits up to 200A @ $6 Each Circuits [ ) Feeders/Circuits Up to 200 A @ $6 Each
Other (Specify) JAJ S � Reconnected Feeders/Circuits O @ $2 Each
Manufactured Home Park Lot Supply ( ) $35 Each Special Inspection Fee ( ) Hours @ $80 Per Hour
Plus Miles @ The IRS Mileage Rate of
Detached Garage or Other Associated Structure Detached Garage or Other Associated Structure
New Home Service/Power Supply 0400 ampere @$35 New Home Service/Power Supply 0-400 ampere @ $35
New Feeders/Circuits ( ) @ $6 Each New/Extended Feeders/Circuits ( ) @ $6 Each
Other (Specify) Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) State Surcharge = $5.00
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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 isgreater)
PD �J � �5�/��� (� /�� �1/ �3 � Receipt #
Requests for Electrical Inspection (R I) 'fh 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 :
Rough- In Inspection (s) Date Walt Lusian, Electrical Inspector
952 . 934 . 0229
Final Inspection Date
WALT LUSIAN
IAEI Certified
Master Electrical Inspector
ITLABOR
MINNESOTA DEPARTMENT OF
INDUSTRY
16275 Sheldon Ave.
Eden Prairie , MN 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
Owner/Occupant County
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Job Address - Street
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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 in the
amount of by (fourteen days from the date issued )
A service charge of $30 will be added for all dishonored checks.
Inspector Name and Number For Department Use Only
Inspector Telephone Number
Ins pe or ail ddress/W ite
Inspector Signature