Electrical Permit - Permit# L21-42 - 4695 Shoreline Drive - 10/20/2021CITY OF SPRING PARK OFFICE USE ONLY
ELECTRICAL PERMIT Electric Permit # L� I- q �
Date Issued: C4 aC u1 Receipt #
PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES
Quantity DESCRIPTION OF WORK FEES sub/Total
Includes up to 4 circuits if more than 4 see Sec, D below $ 40.00 per 140.00
Additional Inspection trips for Rein spection/Bonding/Equipotential Plane/etc. $ 40.00 per
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,
fees as per C & D below but not to exceed $ 125.00 per unit
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
1. Up to and including a 200 amp service $ 50.00 each
2. 201 amp to 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
State Surcharge .0005 of the permit fee (minimum of $1.00) 1 1.00
TOTAL AMOUNT DUE I$ 50.50
not forget State Surcharge Fee)
You must ca11952-442-7520 when work is ready for inspection!
Describe Proposed Work: Replace existing Fire Alarm Control Panel with Simplex 4007; add new duct detectors to existing RTU's; add 1 pull station
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. 4695 Shoreline Drive
OR Legal Description: Lot: Block: Subdivision:
Property ID (PIN No):
Applicant is: Contractor: [A Or Owner: ❑
111*1:il
Contractor/Company Name: Johnson Controls Fire Protection LP/Nancy Rosenow License # TS000557
Address:2605 Fernbrook Lane N, Suite T City/State: Plymouth zip:55447
Telephone: Office/Home: 7( 63 ) 585 - 5113 Mobile: 6( 12 ) 704 - 3160
E-mail: nancy.rosenow@jci.com Fax: () -
Builder/Owner Name: Ridgeview Medical Center
Address (if diff. from Site): 500 S Maple Street
Telephone: Office/Home: g( 52 ) 777 - 4774
City/state: Waconia MN zip:55387
Mobile: �} -
E-mail: mike.kirsch@ridgeviewmedical.org 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 PERMIT. 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 NOT
COMPLETED WITHIN 12 MONTHS OF VALIDATED DATE AND, THAT I AM RESPONSIBLE FOR ENSURING THAT ALL REQUIRED
INSPECTIONS ARE REQUESTED IN CONFORMANCE WITH THE STATE BUILDING/ELECTRICAL CODE.
Signature: Date: 10/18/2021
PAYMENT MUST ACCOMPANY APPLICATION (Be sure to include State Surcharge in payment)
❑ 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
V Visa/Master Card
Account Number
Credit Card Owner Billing Address: 2605 Fembrook Lane N
�i Street Address
Expiration Date CSv
Plymouth MN
City, State
Nancy Rosenow
Payment AuthorWtion Signature (REQUIRED) Print Name on credit card (REQUIRED)
Amount to be withdrawn
55447
Zip Code
��SPEI� TLLC
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952-442-7520 Fax 952-442-7521 888-446-1801
Sold To
Johnson Controls
Sales Receipt
Date
Sale No.
10/27/2021
7460
Payment Method Check No.
Visa
Description
Qty
Rate
Amount
Electrical Inspection/Permit Fee - L21-42 - 4695 Shoreline Dr
State Surcharge - Electrical
49.50
1.00
49.50
1.00
Total $50.50