P - 75175Minnesota Departme of Labor and Industry
443 Lafayette Roa orth
St Paul, MN 551 2
Phone: (651) 2 5�4
TTY/MRS: (65 297-4198
www.electric te.mn.us
Contra or Re uest for Elec�ical I
Date Rough-In Inspedion Required?
4/25/08 Cnnt�flnFn� Mi �et Crhorl� �lo All Rn� inl
�
1040 HACKMAI�f CIRCLE
BRIAN HALGRIMSON
Owmer Telephone Number(s) —
(763) 574�8'Y79
ContradorName
J ANDERSON ELECTRIC
tion — One Famil Dwellin /Associated Structure
y� 3ingle Inspe�ion Other Than Rough-In: ❑ Ready Now
:ctions Contractor Must Schedule All Final Ins 'ons ✓0 Will Schedule
City/Township County
FRIDLEY �,l�Gf /�
Project Description
DISHWASHER 8 MICROWAVE CIRCUIT, OUTLET
FRIDGE, GFI
Contractor Mailing Address
900 6TH ST NW, MAPLE LAKE, MN 55358
Contrador E-mail Address Electrical U61ity
�U1 lori@jandersonetectri�c�m
tho Si na r Coritrac�or Lic�nse Number Job/Projec� Corrtact Person
CA04572 BRENT
Fee Calculation
New Home or Associated Structure Euisttng Home/Structure Remodel or Addition
New Dwelling Servic:e/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401— 800 ampere @$60
New Dwelfing Feeders/Circwits
� rezvro�mvnwncr - v
�cuits (in additlon to
To 200 A [cD $6 Each
Other
Detached Garage or Other Associated Structure
New Servicc�//Power Supply 0— 400 ampere �$35
New Feeders/Circuits ( ) � $6 Each
Other (Speafy)
Newr Servic�/Power Supply
New Senric�e/Power Supply
N�n+/Extended Feeders/Cin
r 3 1 Feeders/circuits
0 — 400 ampere � $35
401— 800 ampere @ $60
b— Up to 15 Feeders/Eiraiits
$6 Each or 16 to 30 $100 �� $
— More Than 30 Fe�ers/Circufts
its U� to 200 A Ca� $6 Each
Detached Garage or Other Associated Structure
New Servic�//Power Supply 0— 400 ampere @$35
New/Extended F�ders/Circuits ( ) @ $6 Each
Reconneded Fpeders/Circuits ( ) � $2 Each
Total (the fee calculated above or $35 multiplied Total (the f� calculated above or $35 multiplied
by the number of requir� inspecdon trips, by the number of r�uired inspedion trips, $35 ��'/a
whichever is greater) whichever is greater)
Requests for Electrical I�paction (REh with a fee oi 5250 or I�s explre 12 mornt�s from the flll� date. The conUactor m�t hare the �rk completed wlthin
the 12 mo�h perlod or submit another REI that includes the I�pectlon fee for the uncomptebed work. I��on te� do not carry over fram one REI to
another.
A service charge of S30 wili be adde� tor all dfshononed chec�.
1 hereby certify that I irispeded the electrical ir�llation herein on the date.s stated: For D�oartmer�t Usa Anlv
Rough — In Inspection(s)
Inspection
i ms ma�na� can oi
TDD (6b7) 287-4188.
REI 02 (6/0'i�
Date
Date
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