P - 83323t1VULtT Fridley, Minnesota 55432 FAX (612) 571-1287 �g ��� 6
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REQUEST FOR ELECTRICAL INSPECTION
"'X'" Below Work Covered by This Request
Add pep. Type o1 Buildinq Appliancss 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 Milk Ta�k
Farm Other pec� v ther ISpecityl
t r ueci y ther Olher �
Compute lnspection Fee Below
1+ Fss SsrvicsEntrsneeSizs tl Fae Feeders/Subleeders p Fee Circwta
Otol00Am Oto30Am S Oto30Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am Above 100_Am s Abov 100_Am s
Transformers Remote Control Circ. Partial�Other Fee
Signs Special Inspection TOTAL FEE
Remarks ..i S �'
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qouph-in � Date �, th� Elsctrical
> � . Inap�ctor, h�r�by
c�rtify tMt th� ebov�
Final �''�p insl»ction has be�n
msde.
This reduest void - �
18 nanths fi� s 5� o
, �•� � ��„�1�! ��OIJ<T �tJUY<� �1i6 ���i� 1��•� �- -� ' _ - - _ _ _ _ __ _ __
T�,S ,�q�eg� �o,d � � 10 0 8 6
18 months from O �
67
Resquest Date flre No. Rouph-�n InsDecuan
Required? �Ready Now C] W��� Notify Inspec-
% �+ � �' � Ves ❑ No tor When Ready
icensed ElecVical Contractor 1 hereby rsquest inspectlon of above
Owner electrical work instellsd at:
Street ddress. Bot or Rou No. City
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Occupant IPRINTI Pnone No.
Power Su I�er . Addr s
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Ele � al Contrector ICo nv Namel Contractor's l�cense No.
Maillnp Address ( ntractor q Owner Maki p Inatailation)
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AuMorized S�pnature (Contractor Owner Mak�nq Installation hon Number
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