HomeMy WebLinkAboutElectrical Permit 12. 356 qwsol
HOMEOWNER REQUEST FOR ELECTRICAL INSPECTION
Date Rough-In Inspection Required? O Yes Inspection Other Than Rough-in : O Ready Now
c , j Z 1 Homeowner Must Schedule All Rough-In Inspections Homeowner Must Schedule All Final Inspections O Will Schedule
Address of Inspection — Street Project Description :
e Ur i [
Owner Name P' 04 ` 3 '1 brs�*l+l
Owner Phone
Home : Cell : 95Z - 200 ^3614
Owner Mailing Address (if different from above) Electrical Utility
By signing this document, I certify that I am th owner as defined by Minn. Stat.325.01 and will legally perform the electrical work.
Owner Signature
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FEE CALCULATION
New Home or Associated Structure Existing Home/Structure Remodel or Addition
New Home Service/Power Supply 0400 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/
( ) 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 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) 7 Reconnected Feeders/Circuits ( ) @ $2 Each
Other (Specify) State Surcharge = $5 . 00 J
TOTAL (the fee calculated above or $35 multipli d by t TOTAL (the fee calculated above or $35 multiplied by the
number of required inspection trips, whichever s re er) number of required inspection trips, whichever is reater) /
(A401:5i'5� p6ill S^ ( Receipt # 12,125 c3
Requests for Electrical Inspection EI) 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 :
Rough-In Inspection (s) Date Walt Lusian , Electrical Inspector
952 . 934. 0229
Final Inspection Date
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WALT LUSIAN
IAEI Certified
Master Electrical Inspector
;5_ MINNESOTA DEPARTMENT OF
ct LABOR 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
o z�- 13 r Z 035 9 - z 1 - 12
Electrical Contractor/Installer License Number
dI21�01�NE
Owner/Occupant County
Job Address - Street Cit7nship
This Order for Payment is for additional fees associated with the above referenced Request for Electrical Inspection .
Fee Calculation/Explanation
Return this Order for Payment with your check payable to the in the
amount of by 10i9 / � G (fourteen days from the date issued)
A service charge of S30 will be added for all dishonored checks.
Inspector Name and Number For Department Use Only
Inspector Telephone Number
Insp cto E- mail Addre /Website
nspector Signat e