P - 83333f1VLLLl Fridley, Minnesota 55432 FAX (612) 571-12E3�
RE�UEST FOR ELECTRICAL INSPECTION
"'X'" Below Work Covered by This Request
Add pep. ype ot Buildin9 Appliances Wirsd
Home Range
Duplex Water Heater
Apt. Building Dryer
Commercial Bldg. Furnace
Indust�ial Bidg. Air Conditioner
Farm ther pec� v
t r ueci y t e�
Compute lnspection fee Below
� �'��0
Equ�pmsnt Wired
Temporary Service
Lighting Fixtures
Electric HeatinQ
Silo Unloader
Bulk Milk Tank
the� lSaecit�!
Other
a � Fee ServieeEntrane�Si:s k Fee Feeders�Subleeders � Fee Circuita
0 to 100 Am 0 to 30 Am s 0 to 30 Am
101 to 200 Amos 31 to 100 Amps 31 to 100 Am
igns
n
� final /
�
Thig repuest vo�d•�
,8�b�«5},�, 26600
This request vo�d
18 months from
ire
L io -��3- �8
❑ licensed Electncal Contractor
�wner
`Street Address, Box or Rout No.
/ � c,
OccupunylPRINTI /
�a
Electrical onuactor ICompany
W ��
Mailiny ddress trattor O�
AuMorized Sipnstur� (Contract�
Above 100_Am S Above 100_Am ,
Remoce Co�trol Circ. _� Partial/Other F e
Special Inspection
/� 5,�� TOTAL FEE
'fTJ��
Date �. �h� Electrical
� . InsP�ctw. h�r�by
e�rtify tMt tfa nbove
D:+te ��sp�ction hss bssn
--� ..26._ m.a..
�S� 10090
%a0b
iph-in InspecUOn
lu�red? �Readv Nuw Q Will Not�fy InSPec-
]Yes ❑ No ror Wben ReadY
1 h�r�br ��4u�st insPSCtio� of �bov�
elsctricsl wwk i�qtslled at:
�p ��stai�atioi
ik�no Installat
Pnone No.
V� � 6�'�/
Contractor's L�cense No.