P - 83478FRlDLEY Fridley, Minnesota 55432 FAX (612) 571-1287 10 0? 6
RE�UEST FOR ELECTRICAI INSPECTtON
"'X'" Below Work Covered by This Request
Add Rev• Type ot Buildinp Appliancea Wirsd Equipment Wired
Home Range Temporary Service
Duplex Water Heater Lightin Fixtures
Apt. Buiiding Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Fafm . Other Peci V ther (SPecify)
t r ueci y iher Other �
ompute lnspectron Fee Below
N � Fse ServicsEntranesSizs M Fee Feeders/Subfeeders � Fee Circui�a
0 to t UO Am s 0 to 30 Am s 0 to 30 Am
101 to 200 Amps 31 to 100 Amps 31 to 100 Am
Above 200 Am s Above 100_Am s Abov 100_Am s
Transform Remote Control Circ. Partiat�Other Fee
Signs eci I Inspection �!
Remarks S S� TOTAL FEE
/� rl<% 2.f'�
Rough-in Date �, the Elect�ical
. Insvsctor, her�by
certity tMt ehs ebovs
Pinal -�� �^�P G� inspsctio� hss bssn
L � �-� � msde.
This reduest vo�d � '
�8 nionths from 2 6'� �
,�
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Th�s request void ,/ 10 0 7 6
18 months }rom � U Da /
6
Request Date Fi�e No. Rouph-in InsDection
�%� � Y �� Re❑quired? a �Ready Now Q W�il NoUfv InsPec-
� 1'es No tor Whe� Ready
❑ licensed Electncal Contractor I hereby roqwst inspechon of above
�wne� alsctrical work inetallsd at:
�ireet ��s, Bo� r Rou No. Citv
�' S� �� �21�L.�
Occup�pLJi�itJT) Pno�ie No.
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Power SuDPl�er � . Addre55/�
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Electncal Contractor IC�ny� 1 Contractor's L�cense No.
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Mailinp Address (Co ctor q Owner Makinp Instailauonl
AuMorized Sipneturs (Comractor r Mak�np Installation) Phone Number
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