P - 84703FIZlDLEY v'V v Fridley, Minnesota 55432 FAX (612) 571-1287 1 Q� 1 7
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REQUEST FOR ELECTRICAI INSPECTION
""X'" Below Work Covered by This Request
Add Rep. TYDe o1 Bu�idinq Appliancss Wirad Equ�pment Wired
Home Range Temporary Service
Duplex Water Heater Lightin Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bidg. Air Conditioner Bulk M�Ik Tank
Fa�m ther Pec� v ther l$Decifyl
< < ueci v ther Other
Compute lnspection Fee Below
a Fse ServicsEntrsnc�Size p Fee Fesders�Subfeeders � fee Circuita
Otol00Am Oto30Am s �to30Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am Above 1�—Am s Above 100_Amps
Transformers Remote Control Circ. Partial�Other fee
Signs , — Special Inspection �
Remarks i S /��'� TOTAL FEE
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Rouph-in , Date � �h� Electrical
. Inap�ctor, hsr�by
csrti}y thst the ebovs
final �^�P � insv�ction haa been
,�, made.
This reduest void �
18 nant f
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This request void 1� J 17
18 months from
�.s - �U �<37�
R u Date Fne No. Rouph-�n Inspection
ReQuired? �ReedY Now Q W�II NoUfv InsPec•
�� t� ,L� I� 19 ❑ Yes ❑ No tor When Readv
�Llcensed Elec r�cal Contractor I h�r�by request inspecaon of above
Owner sl�ctncsl work installed at:
Street Address, Box or R ute Na. ���v
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Occu t (PRINTI Pnorie No.
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Power Suppl��� . A ss � �� j� �'
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Electrical ontractor ICo ny Namel Contractor's license No.
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AAeillnp Address ontractor w Ownar Makinp Instailat�onl
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AuMorizad SiQnaWrs (Comractor Owner�lalii eq.lr' �tallation) Pho�e Number
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