P - 84592FRIDLEY ba3i unrversiry „ve��uo .� � ��„ � • ,
Fridley, Minnesota 55432 FAX (612) 571-1287 1 Q(� � n
`U L
REDUEST FOR ELECTRICAL INSPECTION
"'X'" Below Work Covered by 7his Request
Add Msp. of Buildinq Appliances Wired Equ�pment Wired
Home Ran9e Temporary Service
Duplex Water Heater Lightin Fixtures
Apt. Building Dryer Electric Heatln
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Mllk Tank
Farm ther pec� v ther (Soec��V)
t r ueci v t er Other
ompute lnspect�on Fee Below
a Fse SsrvicsEntranc�Si:s p Fee Feeders/Subfeeders b Fee Circuits
0 to 100 Am 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 hove 100_Am s
ansformers Remote Control Circ. Partial!Other Fee
y�s Special Inspection S C--d(� TOTAL FEE
Remarks �7
� � ��
Date
� Rouqh-in 1, th� Elecdlcal
. InsDector, her�by
c�rti}y th�t tf�s nbovs
F�pal �^�P /� �nsDection has bsen
,� � med�.
This reduest vo�d
18 nanths from
��� S�iissa�a��-�aii Z� �������v����� .
Th�s request void r� � Q V 1 2
18 months from
/�--� �7s�
Request ace fire No. Rouph-rn InsDecuon
Required? �Ready Nuw Q W�II Nout� tnsDec-
��' ❑ Yes ❑ No tor When Ready
Ucensed Electncal Co�tractor 1 h�rsby requ�st inapection ot abov�
❑ Ow^e� slsctricsl work installsd st:
Street Address, Bo Route No. C itv
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Occupant IPRINTI Pno�,e No,
Power Suppli Ad r ss
�S � �,��/ ,��v-
Elec. [i�cal Contractor ICortpany Namel Contractor�s License No.
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Ma�llnp Address IContrac or w Owner Makln Ins ailationl
� �� L�� `s� - u�0 SS3.� �
AuMonzad Sipnawr� (Contractor Ow r Makinq Installation) Phone Number