P - 82172REQUEST FOR ELECTRICAL INSPECTION �
(� "� � [ � � � Z /� � Minnesota State Board of Electriciry � �
� J �•� 1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 :
(651) 642-0800 www.electricity.state.mn.us '���
Home � �Duplex � �Apt. Bldg
Repair
Air Con er Htg. Equip. I I Water Htr. I I Load Mgmt. I Other.
Dryer Range Elec. Heat Temp. Service 1
"X" above the work covered by this request. Enter remorks in this space and on the back of the white copy
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Cakulate lnspection Fee - This lnspecfion Request will noi be occepfed wi�hout the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OPFICE USE ONLY This request void 18 months from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Request Dafe Rough-in inspection requiredR ❑ Yes ❑ No Inspecfion Other Than Rouglrin: eady Now � Wi�l Coll
��� You musf call the inspector when ready Date Ready:
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address �Street, Box, or Route No.) � Ciy Zip Code
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Secfion No. Township Name or No. �Rang No. Fire No. C,pun � ,
Occupanf i' , ' I Phone No.
Power Supplier �� � � Address
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ON BACK OF YELLOW COPY