P - 83544CIVULLI Fridley, Minnesota 55432 FAX (612) 571-1287
REQUEST FOR ELECTRICAL INSPECTION
"'X' " Below Work Covered by This Request
Add Rep. Typa ot Bu�ldinp Appliances Wired
Home Range
Ouplez Water Heater
Apt. Building Dryer
Commercial Bldg. Furnace
Industriai Bidg. Air Conditioner
Farm Other peu v
� � ueci y ther
Compute lnspect�on fee Below
����7
Equ�pme�t Wired
Temporary Service
Lighting Fixtures
Electric Heatinq
Si lo Unloader
Bulk Mlik Tank
ther ISpecifvl
k Pse SarviwEntranc�Sizs M Fee feaders/Subteeders � Fe
0 to 1 UO Am 0 to 30 Am s
101 to 200 Amps 31 to 100 Amps
igns
n
s Above 100 _ Am S A—
Remote Control Circ. ..►
Specialinspection S
� � aU
o��e
Circuita
0 to 30 Amos
31 to 100 Amps
�.bove 100_Amp;
Partial/Other Fee
TOTAL FEE
1, th� Elsetrie�l
Inapsctor, h�r�by
csrtify th�t ths ebov�
Final �^�P inspsction has be�n
Z �'� mads.
This reduest void y�� �
18 nanths from � !-> r' +� 't''
S3� � .� �
Th�s reques� vo�d � ��' O� � 1 O O 9�
18 months from ��/ /
� (O [�J
Request Dafe f�re No. Rouph-�n InsDect�on
tiequ�red? �Ready Nuw Q W�11 Noufv InsOec-
p� - 8 � Yes ❑ No tor When Ready
Ucensed Electncal Contractor 1 h�r�by r�qwst inspechon ot abow
Owner sl�ctricsl work instellsd at:
Street ddiess, Box or Route N
Occupant (PRINT)
Power Supp ier .
Elec � al Contractor ICompanv I
ized Slanatun
`p Instaila nl
�kinp InSWllation
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Pnone No.
� .S / �/ � �C.JGl� �
Contractm's �icense
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' Pho�e Number
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