P - 80367U-8�9-444 C�l
REQUEST FOR ELECTRICAL WSPECTION �"
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 Htg. 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 Inspec►ion Fee - This Inspection Reqvest will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in fhis box.
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PLEASE PRINT OR TYPE
Re�st Date Rough-in inspection requiredZ ❑ Yes ❑ No Inspection Ofher Than Rough-In: Ready Now ❑ Wiil Call
� O a You must call fhe inspecfor when ready Date Ready:
I, �licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: