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P - 83166
t'KiULt.Y � Fridley, Minnesota 55432 FAX (6 REQUEST FOR ELECTRICAL INSPECTION ""X'" Be1ow Work Covered by This Request Add Mep. Type of Buildinq Appliances Wired Home ��� Duplex Water Heater Apt. Building Dryer Commercial8ldg. Fumace Ind��strial Bldg. Air Conditionef �arm ther peci v t r VeCiiy �te lnspectron fee Below Fse Se�vicsEntrsnceSize 0 to 1 UO Am 101 to 200 Amps �gns f�na� Th�s request vo�d 18 nionths �� Th�s repuest vo�d � 18 months from nequest pate �/ � Licensed Electnca� Contrector ] Owner Street Address, Box �R No, Occupant IPRINT) El��cal Contractor ed � � 's� �J A Equlpment Wired Temporary Service Li fitin Fixtures Electric Heat+n Silo Unloader � Bulk Mllk Tank ihe� lSpecify) Other Fee Feeders/Subfeeders � fee Circuita Oto30Ams �to30Am 31 to 100 Amp5 31 to 100 Am Above t00,Am S Abov 10a Am s Remote Control Circ. — Partial�Other Fe Speciai Inspection S�� TOTAL FEE re � Daie �, th� Elect�ical . InsDSeto►. her�bY ��tify tl�st th� nbovs p��P insDection has been t--/_ m9dl. �---------'------- --------- ��10067 �ao 7 Rouph-in Inspection Flequi�ed? �Ready Nuw Q W��i Notifv Inspec• ❑Yes ❑No �or Wfien ReadY I M1�r�by ��Qu�st inspsction of �bove sl�c�ricsi wwk installed at: .�..� CitV � Pnone No. np I�Stailat�0i ik�^q Insta at .6! 2 Contracto�'s license No. �