Electrical Permit - Permit# L 21-33 - 2463 Black Lake Road - 8/24/2021CITY OF SPRING PARK
ELECTRICAL PERMIT
OFFICE USE ONLY
Electric Pe,,r,L t # L L I -33
Date Issued: C_� vReceipt #
PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES
Quantity DESCRIPTION OF WORK FEES subfrotai
k. MINIMUM FEE PER INSPECTION TRIP
Includes up to 4 circuits if more than 4 see Sec. D below
$ 40.00 per '
Additional Inspection trips for Reinspection/Bonding/Equipotential Plane/etc.
$ 40.00 per
3. RESIDENTIAL One and Two-family dwelling units Up to 3 trips included in fee
1. New Dwelling Unit, up to and including a_200 amp service _
$ 125.00 per unit
2. New Dwelling Unit, 201 amp to 400 amp service
$ 175.00 per unit
3. Existing Dwelling Unit, additions, alterations, or repairs up to & including a 200
amp service,
as per C & D below but not to exceed
$ 125.00 per unit
_fees
4. Existing Dwelling Unit, additions, alterations, or repairs 201 amp to 400 amp service
fees as per C & D below but not to exceed _ _--
-- $_175.00 per unit
5. New or Existing Dwelling Unit, 401 amp service or above _
See C & D below
;. FEES FOR NEW OR UPGRADED SERVICES, TEMP. SERVICES, GENERATORS,
OTHER POWER SUPPLY SOURCES OR FEEDERS TO SEP. STRUCTURES
1. Pp to and including a 200 amp service
$ 50.00 each
2. 201 ato and including 400 amp service
$ 100.00 each
3. 401 amp to and including 800 amp service
$ 200.00 each
4. 801 amp service and above
$ 300.00 each
). FEES FOR CIRCUITS/FEEDERS & TRANSFORMERS
0 to 200 amp
$ 10.00 per circuit
Above 200 amp
$ 15.00 per circuit
Transformers up to 10 KVA
$ 20.00 each
Transformers over 10 KVA
$ 30.00 each
i. MULTI -FAMILY DWELLINGS
Each dwelling unit
ALARM, COMMUNICATION, SIGNALING
Each System Device or Apparatus @
i. WORK BEGUN OR FINISHED WITHOUT
IS
OF LESS THAN 50 VOL
$ 50.00
.50 each
State Surcharge .0005 of the permit fee (minimum of $1.00) 1.00
TOTAL AMOUNT DUE 1 t
(Do not forget State Surcharge Fee
You must call 952-442-7520 when work is ready for inspection!
Describe Proposed Work:
Separate Permits are required for any building, mechanical, fire, or plumbing work.
PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES
Job Site: Street Address:
OR Legal Description: Lot:
Property ID (PIN No):
Applicant is: Contractor Or Owner: ❑
Spring Park, MN Zip:
Block: Subdivision:
Contractor/Company Name: Q0�4 1 & '�kfO ( License #:
Address: �A W . Q,` C_ City/State: Jy Zi
Telephone: Of ce/Home: M� ��` 5% Mobile:
�;Uv
E-mail:
Builder/Owner Name:
Address (if diff. from Site):
Telephone: Office/Home: ( }
E-mail:
City/State: Zip:
Mobile: ( )
Fax:
I HEREBY APPLY FOR AN ELECTRICAL PERMIT, AND I ACKNOWLEDGE THAT THE INFORMATION ABOVE IS COMPLETE AND ACCURATE; I
UNDERSTAND WORK IS NOT TO START WITHOUT A PERMITT_ I UNDERSTAND AND HEREBY AGREE THAT THE WORK FOR WHICH THE
PERMIT IS ISSUED SHALL BE PERFORMED ACCORDING TO THE FOLLOWING: (1) THE CONDITIONS OF THE PERMIT, (2) THE APPROVED
PLANS AND SPECIFICATIONS, IF NEEDED (3) THE APPLICABLE CITY APPROVALS, ORDINANCES, AND CODES, AND (4) THE STATE
BUILDING/ELECTRICAL CODE. I UNDERSTAND THAT THE PERMIT WILL EXPIRE, AND BECOME NULL AND VOID IF WORK IS N " T
COMPLETED WITHIN 12 MONTHS OF VALIDATED DATE AND, THAT I AM RESPONSIBLE FOR ENSURING THAT ALL r;QUIRED
INSPECTIONS ARE REQUESTED IN CONFORMANCE WITH Ti l TATE UILDING/ELECTRICAL CODE.
Signature: Date:
PAYMENT MUST ACCOMPANY APPLICATION (Be sure to include State Surcharee in navment
❑ Check attached — Check # MAKE CHECKS PAYABLE to MNSPECT
EMAIL: electrical@mnspect.com
FAX: 952-442-7521
MAIL/DELIVER: MNSPECT, 235 West First Street Waconia,MN 55387,
�i Visa/Master Card = , _ T _ $
r/ Account Number V /� Expiration Date CSV fAmount to be withdrawn
Credit Card )w-eC Billing Address: i�1 mck5 . L� t• �CJI I �--K ICJ
Street Address City State Zip Codg
44D
Paymen Authorization Signatur (REQUIRE ) Print Name n credit card (R QUIRED)
952-442-7520 Fax 952-442-7521 888-446-1801
Sold To
Xtreme Electrical Svcs
Sales Receipt
Date
Sale No.
8/24/2021
7399
Payment Method Check No.
MasterCard
Description
Qty
Rate
Amount
Electrical Inspection/Permit Fee - L21-33 - 2463 Black Lake Rd
State Surcharge - Electrical
80.00
1.00
80.00
1.00
Total $81.00