P - 82628i
U��76-992 �
REQUEST FOR ELECTRICAL INSPECTION �°��°
Minnesota State Board of Electricity � `
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us '�
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner tg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs From validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required? ❑ Yes ❑ No Inspection Other Than Rough-In: gp Ready Now ❑ Will Call
���� (� You musf call the inspecfor when ready Date Ready: "
I,�.licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: