P - 80327`U-892-566 [�
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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity �
1821 Universiry Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���
(651) 642-0800 www.electricity.state.mn.us
Air Conditioner Htg. Equip. Water Hir. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks iri this space and on the back of the whiie copy
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNEGTED IF NOT GOMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request wid 18 months from validation date printed in this box.
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I Date Rough-in inspecfion required? ❑ Yes ❑ No
i��� 0O You must call the inspecror when ready
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PLEASE PRINT OR TYPE
Inspecfion Ofher Than Rough-In: �eady Now ❑ Will Call
Date Ready:
l,�licensed contractor ❑ company ❑ owner hereby request inspection of the above elechical work at: