P - 77518�{ (� REQUEST FOR ELECTRICAL INSPECTION
� 1_ J`� �`� 613 � Minnesota Board of Electricity
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Rough-in Inspection Required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now �iVill Call
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I certify that I am the l�,[ICENSED CONTR,4CTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Sde SVeet Address
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Please Provide Two ( Phone Numbers Inclu�
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ity Address
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OF ELECTRICITY COPV
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City of Fridley
6431 University Avenue N.E.
Fridley, MN 55432
In accordance with my contract with the City of Fridley, I, Robert H. Clauson, am
requesting payment for fees in the record shown on inspection forms, certified by
me that the inspections have been completed.
Number of Electrical Forms �_
Total Fees Listed 3 g �—'
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�c 1 3't�5�
State Surcharge `� 'f � � S �
IVet Fees _ 1�3 y 7, S°
Net Fees at 80% �� 7� " 46
Robert H. Clauson
ElectricalI pector
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Ron Julkowski
Building Official
Date