P - 75552Minnesota C�epartment of Labor and Industry
443aLafayette Road North
St. Paul, MN 551�i'-4342
Phone: (651) �-5064
TTY/M RS: 1) 297-4198
www.elec .state.mn.us
Con ctor Re uest for Electrical I
Date Rough-In Inspection Required?
7�28�08 Contractor Must Schedule All Rou I
Address of Inspection — Street
6736 WASHINGTON ST NE �
Owner Name
JENNIFER HANSON
Owner Telephone Number(s) — Include Area Code(s)
(763) 571-4946
Contractor Name Contra�
ection — One Famil Dwellin /Associated Structure
Q Yes Single Inspection Other Than Rough-In: ❑ Ready Now
Ins ections Contractor Must Schedule All Final Ins ections ✓0 Will Schedule
CitylTownship Counry
FRIDLEY ANOKA
BATHROOM REMODEL
_ !/Y1?.�z�o ���a�z,..�
BROTHERS ELECTRIC 3447 CEDAR AVE SO, MPLS, MN 55407
Contractor Telephone Number Contractor E-mail Address Electrical Utility
(612) 721- 60 lettuce5175@yahoo.com
Contractor Au ' ed Sig ture Contractor License Number Job/Project Contact Person
CA00317 AMY
Fee Calculation
New Home or Associated Structure
New Dwelling Service/Power Supply 0— 400 ampere @$35
New Dwelling Service/Power Supply 401 — 800 ampere @$60
New Dwelling Feeders/Circuits
New Home —
I Feeders/Circuits - $100
cuits (in addition to
To 200 A Cc� $6 Each
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
0 — 400 ampere @ $35
( ) @ $6 Each
Existing Home/Structure Remodel or Addition
New Service/Power Supply 0— 400 ampere @$35
New Service/Power Supply 401 — 800 ampere @$60
New/Extended Feeders/Circuits — Up to 15 Feeders/Circuits
3 Feeders/Circuits $6 Each or 16 to 30 $100 $� 8
New/Extended Feeders/Circuits — More Than 30 Feeders/Circuits
Feeders/Circuits U to 200 A $6 Each
Rec�nnected Feeders/Circuits
( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New Service/Power Supply 0— 400 ampere @$35
New/Extended Faeders/Circuits ( ) @ $6 Each
Reconnected Feeders/Circuits ( ) @ $2
Other (Soecifiil
. �.
Total (the fee calculated above or $35 multiplied TOt11(the fee calculated above or $35 mu 'plie
by the number of required inspection trips, by the number of required inspection trips, �
whichever is greater) $35 whichever is greater) 3�
Requests for Electrlcal InspecUon (REI) wlth a fee of $250 or less expire 12 months from the flUng date. The conVactor must have the work completed wlthin
the 12 month period or submlt another REI that Includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REI to
another.
A service charge of $30 will be added for all dishonored checks.
I hereby certify that I inspected the electrical installaGon herein on the dates stated: Fo Depart ent Use Only .
Rough — In Inspecti (s) Date <7� /d�� � � ��
� � � � � �a
Final Inspection / Date �� Q� G o 1 O
/ �i � � .� .�, .-v�
TDD (651) 297-4188.
REI 02 (6/0�
In dlfferent forms, such as large print,
vr on a[ape. 1 o requesL, C811
Volce or
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