P - 803640-89�-447
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 I I Duplex I I Apt.
Commercial Industrial Farm
Air Conditioner Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above 1he work covered by this request. Enter remarks in this space nd on the back of the white copy c
Po �.v er 5�.�,� p��-�'o r�c�.b l e T_ I/'_ C'o .
U-1--� �r `li �es n�e� fo �J�e C� c,�t ne_e�`c�.
Calculate Inspection Fee - This Inspection Request will not be accepted without ►he corceci fee:
Repair
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This request void 18 monihs from validation date prinied in this box. �
III����������������il�{{�fll��il� ,sb . • �-.
* 0 8 9 9 4 4 7 7*
as �78�� �'��3��-
PLEASE PRINT OR TYPE
Request Date Rough-in inspection required$ ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now [� Will Call
�� �� O You must call the inspecfor when ready Dafe Ready:
1,� licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: