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Permits - Permit# L17-021 - 2478 Black Lake Road - 1/1/201707/03/2017 07:53 FAX. 9524433441 SIGNATURE ELECTRIC CO [a 002 OFFICE USE ONLY CITY OF SPRING PARK Electric Perm' # L P 7 OZ 1 ELECTRICAL PERK UT Dote TRvued- �� R"-Civ # 5 / zZ_ PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES Quantity DESCRIPTION OF WORK FEES Subrrotai 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 Reinspecbon/Bonding/Equipotential Plane/etc. $ 40.00 per to 3 1. New Dwelling Unit, up to and including a zou amp service 2. New Dwelling Unit, 201 amp to 400 amp service 3. Existing Dwelling Unit, additions, alterations, or repairs up to & including a 21 fees as per C & D below but not to exceed 4. Existing Dwelling Unit, additions, alterations, or repairs 201 amp to 400 amp _ fees as per C & D below but not to exceed 5. New or Existing Dwelling Unit, 401 amp service or above :. FEES FOR NEW OR UPGRADED SERVICES, TEMP. SERVICES,.GENERI OTHER POW1!R SUPPLY SOURCES, OR FEEDERS TO SEP. STRUCTURI 1. Up to and including a 200 amp service 2.201 amp to and including 400 amp service 3. 401 amg to and ind ding 800 amp service 4. 801 amp service and above 1. FEES FOR CIRCUI I SIFEEDERS & TRAN; Above 200 amp Transformers up to 10 KVA Transformers over 10 KVA MULTI -FAMILY DWELLINGS Each dwelling unit ALARM, COMMUNICATION, SIGNALING CIRCUITS, OF LESS Each System Device or Apparatus Q FOR INSPECTIONS NOT COVERED ON THIS FORM OR FOR ncluded In %e $ 125.00 per u $ 175.00 per u amp service, $ 125.00 per u rvice $ 175.00 per u See C & D beli $ 100.00 each $ 200.00 each $ 300.00 each $ 10.00 per circuit $ 15.00 per circuit $ 20.00 each $ 30.00 each $ 50.00 per unit TS $ .50 each SPECIAL Hourly charge $ 57.00 per hour E 11PLAN amew iM vir s AftteTftl. iF0 W SM01 OR RNIS)ell; WM4WT PUMT IS 0( T E State Surcharge .0005 of the permit fee (minimum of $1.00) 1.00 TOTAL AMOUNT DUE $ 5 1 Do not forget State Surcharge F®® You must call 952-442-7520 when work is ready for ins ection! Describe Proposed Work: `iV—:rM © Z A-7a 13� LA-r-V- r-04-� Separate Permits are required for any building, mechanical, fire, or plumbing work. Poor Quality Document Disclaimer The original or copy of a document or page of a document presented at the time of digital scanning contained within this digital file may be of substandard quality for viewing, printing or faxing needs. 07/03/2017 07:53 FAX. 9524433441 SIGNATURE ELECTRIC CO 0001 PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES Job Site: Street Address: 'Z4-7 S p'I"'� �' sp�� Park, UN zip. 3g4 OR Legg Description: Lon Block: Subdivision: Property lD (PTN No): Applicant is: Contractor. g Or Owner: ❑ �+ t21r ��GTjz a G License #: tP�V �/ IV Contractor/Company Name: S 16 N ^ Address: I �O Ca� City/State: V 1 6 K �.► A rl Zip: (� 22) 4dq - �4 - Mobile: �2 Telephone: OfFice/IIome: troy 0 G i -r1 c , n, -- 'Fax: Builder/Owner Name: L � --( � V-4 (�tg_ _ GIb1� 443--.2;,A+I Address (if difE from Site): City/State: Zip: 'telephone: Ofiice/Hoine, Mobile: E-mail: Fax: I. HEREBY APPLY FOR AN ELECTRICAL PERMIT, AND I ACIQ30 I UN RSTaND AND k�RkBY AGRTHAT TM INFORMATION E� HAT THE W ETE OR AC CURA 1 UNDERSTAND WORK IS NOT TO S_ R pERMIT IS ISSUED SIJALL BE PERFORMED ACCORDING TO TAND (a4)) THE STATE HE FOLLOWING: (1) Tli1r COND]TIONS OF 71 PERMIT, APPROVED PLANS AND SPECIFICATIONS, IF NEEDED (3) THE APPLICABLE CITY APPROVALS, ORDINANCES, AND CODES, BUILDING/ELECTRICAL CODE. I UNDERSTAND TNATTRE PERMIT WILL E)eW AND BECOME NULL AND VOID IF WORK IS NOT CON(pLETED i�TIliIN t2 MONTHS OF VALIDATED DATE AND. THAT I AM RESPONSIBLE FOR ENSURING THAT ALL REQUIRED INSPECTION N12MSTEnD S C O WITI TI>t STAT BU1LDING/ELECTRICAL CODE. / 1 / l Date: N Check attached Check # MAKE CHECKS PAYABLE to M NSPECT MAIL: MNSPECT, P.O. Box 342, Waconia, MN 55387 FAX: 952-442-751a3t .ti ' DELIVER: Visa/Master J�rl N 1 Nj ptipt Name on credit card (REQUIRlM) MNSPECTLL. -1 M 11-1 Street West • Wecanie, MN We 11002 952-442-7520 Fax 952-442-7521 888-446-1801 Sold To Signature Electric Sales Receipt Date Sale No. 7/5/2017 5122 Payment Method Check No. MasterCard Description Qty Rate Amount Electrical Inspection/Permit Fee - L 17-021 State Surcharge - Electrical 50.00 1.00 50.00 1.00 Total $51.00 ELECTRICAL PERMIT CRY OF MOUND OFFICE USE ONLY Electric Pe it # L t 7 —1 5-0 Date Issued: ? d i Receipt # 5-t PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES Quantity DESCRIPTION OF WORK FEES Sub/Total A. 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 B. 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, 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 C. FEES FOR NEW OR UPGRADED SERVICES, TEMP. SERVICES, GENERATORS, OTHER POWER SUPPLY SOURCES OR FEEDERS TO SEP. STRUCTURES 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 D. FEES FOR CIRCUITS/FEEDERS & TRANSFORMERS 0 to 200 am $ 10.00 per circuit Above 200 am $ 15.00 per circuit Transformers up to 10 KVA $ 20.00 each Transformers over 10 KVA $ 30.00 each E. MULTI -FAMILY DWELLINGS Each dwelling unit $ 50.00 per unit F. ALARM, COMMUNICATION, SIGNALING CIRCUITS, OF LESS THAN 50 VOLTS Each System Device or Apparatus @ $ .50 each G. FOR INSPECTIONS NOT COVERED ON THIS FORM OR FOR REQUESTED SPECIAL INSPECTIONS Hourly charge $ 57.00 per hour . COMMERCIAL PLAN REVIEW FEE (IF REQUIRED) is 25% of Total Permit Fee . WORK BEGUN OR FINISHED WITHOUT PERMIT IS 2X THE REQUIRED PERMIT FEE State Surcharge .0005 of the permit fee (minimum of $1.00) 1.00 TOTAL AMOUNT DUE Do not forget State Surcharge Fee You must ca11952-442-7520 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): Mound, MN Zi Block: Subdivision: Applicant is: Contractor: Ix Or Owner: ❑ Contractor/Company Name: License #:4 Address: �y Lh d I City/State: Edin(2 Zip: SS Telephone: Office/Home: FED )S?)s ;iobile: E-mail: 0dP V I U hMj] C QOQ Fax: (� - I Builder/Owner Name: Address (if diff. from Site): Telephone: Office/Home: (� - E-mail: City/State: Mobile: O - Fax: ( ) Zip: I HEREBY APPLY FOR AN ELECTRICAL PERMIT, AND 1 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 REQUESTE IN CO NF ANCE WITH THE STATE BUILDING/ELECTRICAL CODE. Signature: Date: ❑ Check attached — Check # MAKE CHECKS PAYABLE to MNSPECT MAIL: MNSPECT, P.O. Box 342, Waconia, MN 55387 FAX: 952-442-7521 DELIVER: MNSPECT, 235 West First Street Waconia, MN 55387 ❑ Visa/Master Card — / Credit Card Owner Billing Address: Account Number Street Address Payment Authorization Signature (REQUIRED) Expiration Date CSV City, State Print Name on credit card (REQUIRED) Amount to be withdrawn Zip Code