Permits - Permit# L19-23 - 2478 Black Lake Road - 1/1/2019CITY OF SPICING PARK
ELECTRICAL PERMIT
OFFICE USE ONLY
Electric Permit # L 10(-13,
Date Issued:._ Receipt # 8�?
PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES
Quantity DESCRIPTION OF WORK FEES sub/Total
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 ger 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. 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. 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 for et State Surchar e Fee
$
�L
You must call 952442-7520 when work is ready for inspection!
Describe Proposed Work: OLD'" o M "
Separate Permits are required for any building, mechanical, fire, or plumbing work.
°I 000 3
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PLEASE PRINT OR TYPE ALL INFORMATION AND COMPLETE ITEMS ON BOTH PAGES
Job Site: Street Address:
OR Legal Description: Lot:
Property ID (PIN No):
Spriny- Park, MN Zip: 553 s�
-G Block: -- " - Subdivision:
. b ,
Applicant is: Contractor: 3 Or Owner: ❑
G
Contractor/Company Name: d�cfl.l.l l"?7GC/C i=lG /"L ee- f/"iC,. 1��C' License #: � 06
Address: ;697S' f fir /Z City/State: Z)e /,I I? O R AI Zip: ,5S 3 a'
r
Telephone: Office/Home: (} —� - Mobile: -
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E-mail: o f„ ,4, i l 4 C D m Fax:
d 20 y� � cus�� �7
Builder/Owner Name:
Address (if diff. from Site): y KC //� a(% City/State: / ) ae- 41 d lei Zip:
Telephone: Office/Home: Mobile:(___--) -
E-mail: So le- cif �id M n r i J9� homPS .,»� >7 Cforn 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 REQUEVED IN CONFORMANCE W,IYH THE STATE BUILDING/ELECTRICAL CODE.
Signature:
Date:
PAYMENT MUST ACCOMPANY APPLICATION (Be sure to include State Surchars?e in payment)
o Check attached — Check #
MAKE CHECKS PAYABLE to MNSPECT
EMAIL: electrical@mnspect.com
FAX: 952-442-7521
MAILIDELIVER: MNSPECT, 235 West First Street Waconia, MN 55387
❑ Visa/MasterCard—
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
-MNSPECT-,.
1 __, 2J5 Firsl Slreel Wosi • Waconle. MN 55]B]-1]02
952-442-7520 Fax 952-442-7521 888-446-1801
Sold To
Dean Fowser Electric
Sales Receipt
Date Sale No.
11 /4/2019 6847
Payment Method Check No.
Check 4490
Description
Qty
Rate
Amount
Electrical Inspection/Permit Fee - L19-23, 2478 Black Lake Rd
State Surcharge - Electrical
125.00
1.00
125.00
1.00
Total $126.00