P - 83755- ��. --Cv�cT-rr. . �
Fridley, Minnesota 55432 FAX (612) 571-1287
REQUEST FOR ELECTRICAL INSPECTION
"'X"' Below Work Covered by This Request
Add R Type of Building Appliances Wired
Home Range
Duplex Water Heater
Apt. Building Dryer
Commercial Bidg. Furnace
Industrial Bidg. Air Conditioner
Farm Other pec� v
t r peCify ther
Compute lnspect�on fee Below
++ Fse ServicsEntrsncaSi:e p Fee Feeders�Suhfeeders !1
0 tol00Am s Oto30Am s
101 to 200 Amps 31 to 100 Amps
Above 200 Am s Above 100_Am s
Transformers Remote Control Circ.
Signs Special Inspection
Memarks
Rough-in
Final
Th�s reQuest void
18 nionths�oa► _� -
P�
Th�s request vo�d �
78 months trom
� Llcensed ElecLiical Convactor
�,�-�wner ,/
Street Address, 8ox or Route N$,
�-� � � �,�°�i �U�� ..1;,_ �, S
Occu t IPRINTI
�� � (� �_�l l�� ,��
Power SuDPlier
/��S -�
Elecincal Contractor ICompany Namel
����� � �
Mailinp Addres . ontracto� w Owner
� I '11 1�
Autho�lzed Siflnawre IComractor Own
_�
����2
Equipment Wired
Temporary Service
Lighting Fixtures
Electric Heatinq
Silo Unloader
B�Ik Mllk Tank
ther ISpecit��
Other
Fee Circuits
te
D:� t e
n � z��=
0 to 30 Am
31 to 100 Am s
Above 100_Am ;
Partial!Other Fee
'� TOTAL FEE
I, ths Electrical
Inspector, hareby
cartify that tha above
inspaction has been
�? % made.
��-`� ,�'� ��3�� � � � :� � 2
'��e No. Rough-in Inspect�on
Required? �Ready Now � W�11 NoUfy I�sPec-
❑Yes ❑No tor When Feady
1 hersby request inspection of sbove
electrical work inatalled at:
Cltv .r-
np Installationl
�ki�Q Installation
Pnone No.
W L[ V '
Contractor'S L�cense
imoer
r� � ��