P - 83770Fridley, Minnesota 55432 FAX (612) 571-1287 ��� �� /
REQUEST FOR ELECTRICAL INSPECTION �}
"'X" Below Work Covered by This Request
Add Rep. ..ype of Bu�ldinq Applia�ces Wired . Equ�pment Wired
Home Range Temporary Service
Duplez Water Heater Lightin Fixtures
Apt. Building Dryer Electric Heatin
Cortxnercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Fdrm - O�her peu v �her ISpecity)
t r yeci(y Iher Other � �
Compute lnspection Fee Below
a � Fee Ss�vicsEntranceSize p Fee Feeders�Subfeeders b Fee Circuits
0 to 1 UO Am 0 to 30 Am s 0 to 30 Am
101 to 200 Amps 31 to 100 Amps 37 to 100 Am
Above 200 Amps Above 100_Am s Above 100_Amps
Transformers Remote Control Circ. Partial!Other fee
Signs Special Inspection g=�D�J TOTAL FEE
Remarks n
��c.fn l T )� �i7�i(n. -
Rough-in Date �, the Electrical
. Inspecto�, hersby
certi}y that ths nbove
Flnal � �^�P inspection has bsen
,2� made.
T�is reduest vo�d - �
18 nio��ttorp
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This request vo�d � '��� �� d; � 4
78 months trom �' �:I�L� �
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Requ t ace Fire No. �ReqUhe�n�lnspection �Ready Now � W�II Notit� tnsDec-
` ior When Ready
�_ �S�/� ❑Yes ❑No
� Licensed Ele t�cal Cont��ctor 1 hen6y rsquest inspechon of ebove
wner electrical work inatallsd at:
Street AddrB�, Box or Route No.
,��n �_,
Occupant PR�NT)
_T 7 �
Power $uppli� .
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Electrical Contractor ICompany Name)
�(�-� .� .,/��
Mailinp Addr _ (Contractor o� Owner
' L 4-�
AuMorized Sic�+awra IContracto� Own
A
kinp Instailation
Makinq Installati
Pnone No.
��n L���J�QI
Contrector's l�cense No.
Number
1 l _ �., Q �?