P - 84001��V Fridley, Minnesota 55432 FAX (612) 571-12 �� o� O
REQUEST FOR ELECTRICAL INSPECTION
""X"' Below Work Covered by This Request
Add Rep. Type ot Buildinq Avv��ances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Lighting Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bidg. Air Conditioner Bulk Mllk Tank
Fdrm Other peu v Other (Soec�ty�
t r uecify ther Other -
Compute lnspection Fee Below
N Fse SsrviceEntranceSi=e # Pee Feeders�SubPeeders b Fee Circuits
0 to 100 Am 0 to 30 Am s � to 30 Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am s Above 100_Am s Above 100_Amps
Transformers Remote Control Circ. Partial!Other Fee
Signs Special Inspection S�p(� TOTAL fEE
R ema r ks �,.�..
� ,
Hough-in Date �, ths Electricsl
. Insvector, hersby
cerLfy that the ebove
Final ' Date ��spsction has been
. �J" .. ^.�.^ mede.
This repuest vo�d � �
18 nanths fr� 5 � b�
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Th�s request void % j���
18 months trom � (� 7
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Request Date Fire No. qough-�n InspecUOn
Requ�red? �Read� Nuw � W�II Noufy tnspec-
�� ❑ �es ❑ No tor When Ready
L�censed Electncal Contractor I heraby request inspection ot above
Owner alectrical work installed at:
Stre Address, Box o� Route No C�ty
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Occupa�t IPRINTI Pnone No,
Power Suppl. er . A ress
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EJ� ncal Contrector IC ny Namel
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Mall n Addres IContractor or Owne� akinp Insta�lation)
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AuMorized Sipnature (Comractor Ow�er Makinp Insta lation
2�1--� �l �1 SfO�
Contractor'S License No.
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Phone Number
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