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HomeMy WebLinkAboutElectrical Permit 12. 0087 I .Yry # lf �: �6 -j 5 3 4-- ( Reset Form Print Form I 3,5- -' y l 0 For Office Use Only Amount of Check: �// PermitTRAK Number: _ 4711VNf5tTil ©EP}�RfNtEMI 157 CO Z(� ELE /2- / LABOR INDUSTRY' "` 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. 03/08/2012 * Check One Box: 151 Contractor or ❑ Homeowner * Check One Box: ❑ New Bldg or E Existing Bldg * Check One Box: 0 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 5148 E. OAK POINT SCOTT * Project Township: (Please enter only the township name * Project City: * Project Zip or the city name, not both) PRIOR LAKE * Owner Name * Owner Phone Owner Cell Owner E -mail SUE JENSEN * Company Type (check one box) 2 Electrical Contractor ❑ Technology System Contractor * Company License Number * Company Name EA001695 SOUTH SIDE ELECTRIC, INC. * Company Address * City * State * Zip Code 9201 E. BLOOMINGTON FRWY #X BLOOMINGTON MN 55420 * Company Phone Company Cell * Company E -mail Contact Person and Phone Number (952) 888 -5500 MIKE VESELY * 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 ❑ Yes or ID No Will Schedule Directions to Project Site 60287: INSTALL AND WIRE EZ HEAT MAT IN BATHROOM WITH Project Site (Contact Person and Phone Number) PROGRAMMABLE THERMOSTAT. Electrical Utility TOTAL INSPECTION FEE from REI fee worksheet, or $35 multiplied Enter Inspection Fee Here » * 35 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) 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 REI forms together with the applicable fees to: MN Dept Labor & Industry, PO Box 64227, St. Paul, MN 55164 -0227 ,- 77.) REI 10 (4/11) REI_10_OneAndTwoFamily.doc (Revised 4/1/11) (;//// Order for Payment Date Request for Inspection Serial Number Date Filed 3-2Z-/ /z, -paw 3 - f -/ Electrical Contractor /Installer l i cens e Number Owner /Occupant ' County 1° Cie Job Address - Street , , ityfT nship .5 / .E.4.7 0177 . dP`i W �i�/De 1 This Order for Payment is for additional fees associated with the above referenced Reques • -:.•r. • - •. Fee Calculation /Explanation /` 4..1 /9222/r/D/t//9L /A/ <R0(&..• �� r ifif 4 . I\ 5< ) °('‘ _ � J M aw r`.� • Return this Order for Payment with your check payable to theallIMIIIIIMI in the amount of $ __ by _ (fourteen days from the date issued) A service charge of S30 will be added for all dishonored checks. Inspectoy ame and Number For Department Use Only Gc /�J %T Z--/t57,01/ Inspector Telephone Number 7 �.3/ azz 9 Inspector E -mail Address/Website Ins') ctor i ure ✓_„ l 5 R , c � ` " uz1(.. 51. ��.- . IW�w�` A Gtr. � 56'"t' IN .