P - 81458r�V V�..tY Fridley, Minnesota 55432 FAX (612) 571-1287
REQUEST FOR ELECTRICAL INSPECTION
'"X'" Below Work Covered by This Request
Add ReD• Typa ol BuildinQ ApDliancsa Wirsd
Home Range
Ouplex Water Heater
Apt. Building Dryer
Commercial Bldg. Furnace
Industrial Bldg. Air Conditioner
Fdffll - ther peu v
[ r pecl y �her
.,ompute lnspection Fee Below
f a •
Equlpment Wired
Temporary $ervice
Lighting Fixtures
Electric Heatinq
Silo Unloader
Bulk Milk Tank
the� ISoec�tvl
n,ne.
11 F�a Ssrv�csEMrene�Sus k Fee feaders/Subfeeders p fee Circuits
0 to 1 UO Am 0 to 30 Am s 0 to 30 Am
101 to 200 Amos 31 to 100 Amps 31 to 100 A
�gns
in
P�nal
T�is request vo�d
18 nanths f�om
m
Above 100_Am S Above 100_Am s
Remote Controi Circ. v Partial�Other Fee
5pecial Inspection
. � S,� TOTAL FEE
r
Date �, th� Electricsl
Inapsctor, h�r�by
csrtify thst th� nbovs
���P �+ insp�ction hss bsen
�"Z-- —i�"/7 msd�.
T�,S ,�q�es� �o,d ^ ��O 10 0 9 9
18 rrwnths from ��//
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Request Date fire No. Roup�-in InsDection
�_ / ReQuired? �Read� Now Q WiU Nouf� Inspec-
� ❑ Yes � No tor When Ready
❑ l�censed Electncal Contractor 1 h�r�by rsqusst inspec6on ol abovs
�Owner
sl�ctrical work inatallsd at:
Street Address, Box or Rou[e No_ _.
Occupdntl
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Ma i�
AuMo�h
tractor ICompany Name)
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�3 IContractor o� OwMr
pnature
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�0 ��stailation
�.ki�p Installati
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Pnone No.
� 2�i� /J! d,
Contractor'S license No.
umber
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