HomeMy WebLinkAboutElectrical Permit 12. 262 Reset Form I Print Form 1
For Office Use Only
Amount of Check: Check Number: PermitTRAK Number:
) - MINNESOTA DEPARTMIENT OF ELE
L ABOR & INDUSTRY
'` Request for Electrical Inspection (REI) (permit)
443 Lafayette Road North
St. Paul, MN 55155 -4342
Phone: (651) 284 -5026 One- and Two - Family Dwellings
www.dli.mn.gov i 2--- Z
Fields marked with an asterisk * are required (as applicable). * TOD Y'S ATE
Incomplete, inaccurate, or illegible forms may be returned to the submitter. ,7 5 I
* Check One Box: . C ontractor or ❑ Homeowner * Check One Box: ❑ New Bldg or Existing Bldg
* Check One Box:' One- Family Dwelling (homeowner or contractor) OR ❑ Two - Family Dwelling contractors only) is unlawfuitfoThomeowners to perform electrical work on property that is rented, leased or occupied by others) y)
* Project Location (number & street name) * Project County
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* Project Township: ( Please enter only the township name * P sct City: * Project Zip
or the city name, not both) i � IL( ( ss - 7
* Owner Name * Owner Phone Owner Cell Owner E -mail
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* Company Type (check one box)
y a _ Electrical Contractor ❑ Technology System Contractor
* Company License Number * Company Nara
WA 000 083 , -\ A--- ,I(1.6" C1 Lam
* Company Address 1* Cit * State * Zip Code
9 01 w \, lfA Avi S 1 05,,,lL.4 4//// SS 33`7
* Company Phone Company Cell *Company E -mail Co tact Person and Phone 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) El Ready Now or Yes or ❑ No
Will Schedule
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Directions to Project Site
Project Site (Contact Person and Phone Number)
Electrical Utility
TOTAL INSPECTION FEE from REI fee worksheet, or $35 multiplied Enter Inspection Fee Here » * �)
b the number of re uired ins section tri ss, whichever is s 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) * 7S '
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 64218, St. Paul, MN 55164 -0218
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REI 10 (4/11) REI_10_OneAndTwoFamily.doc (Revised 4/1/11)