P - 83205r1UULtT Fridley, Minnesota 55432 FAX (612) 571-1287 ���� 4
REQUEST FOR ELECTRICAL INSPfCT10N
"'X'" Below Work Covered by This Request
Add Nep. Typa ot Bu�iding Appliances Wi�ed Equipment Wired
ome Range Temporary Service
Duplex Water Heater Lightin Fixtures
Apt. Buildi�g Dryer Electric Heatin
Commerciai Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Fdrm ther peu v ther ISpec�fvl
I r UeCi V ther Other �
Compute lnspection Fee Below
a Fee ServieeEntranc�Sias k Fee Feeders/Subfeeders � fee Circuits
0 to 1 UO 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 Above 1 QQ _ Am s Abov 100_Am
Transformers Remote Control Circ. Partial�Other F e
Signs Specialtnspection
A ema r ks ,�,,.
S J� TOTAL FEE
Rouph-in Date �, tn� Eleetriesl
. Inspsetor, hsrtby
certify that th� above
F�nal . �'��P inspsction hss bs��
d.. m�d�:
This request vo�d ' � /"� 4 �
18 nanths from U1
� ��._���.�..��---� .�
This request vo�d • /��q� � 0 O/ 4
18 montbs trom L�/O / �
7( V
Request Date Fire No. Rouph-in Inspecuon
Requ�red? �Ready Nuw Q Wii� NoUfy tnspec-
� � ❑ Yes ❑ No tor When ReadY
� Licensed Efect�ical Contractor 1 h�r�bv r�qu�st inspsction of abov
wner slsctrical work install�d at:
Street Address, Box o�r� qos�[e No. City
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Occupn IPRINTI /^, P�one No.
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Power $uppl� Addres
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Electncal Con ractor ICompany Namal Contractor's L�cense No.
Malllnp Add�es ontractor w Owner Makinp InstallaUon)
AuMor�Zed Sipnetur� (Contractor Owner Mak�np Inatallation) ' �one Number
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