P - 82936fl�ii.�l.t.i Fridley, Minnesota 55432 FAX (612) 571-1287 °� p�`�. <�� �
R lo� `�t.' 6 �
REQUEST FOR ELECTRICAL INSPECTION
'"X" Below Work Covered by This Request
Add Rep � Typa ot Building Aov��ances Wired Equipment Wired
Home Range Temporary Service
Duplex Water Heater Lightin Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Mllk Tank
Fdrm Other pec� v ther ISpecitvl
t r pecify t er Other �
Compute lnspect�on fee Below -
a Fse SsrvicsEntranc�Si:e k Fee Feeders/Subfeeders !7 Fee Circuits
0 to 1 UO Am 0 to 30 Am s 0 to 30 Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am Above 100—Am s �„"'' Above 100_Am
Rouph-�n
F�nal
This reques ''�o�i �M
18 nanths f�p/n{-� � f i-a
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This request vo�d � �� �
�s �,oncns r.om
Request D te
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Licensed Electrical Contractor
Owner
Street Addr ss, 8ox or oute No.
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Occupunt IPRINT)
Elect c I Contra tor ICompa ,
�
Maillnp Address ICo r ttor q
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AuMorized Sipnatun IComract
VU1e I, th� Electricsl
� . Insp�ctor, he�sby
c�rtifv th�t tM ebov
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��69 10072
Rouph-�n InsDect�on
Ne4uired? �Readv Now Q W�II NoUfv InsOec•
❑Yes ❑No tor When ReadY
I h�reby requsst inspectlo� of sbov�
slsctriesl work installsd at:
Ciry
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Pnone No.
/ C_-rJ ! L V �
Contractor'S L�cense No.
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nstaiia onl ` �
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