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REQUEST FOR ELECTRICAL INSPECTION �
Minnesota Staie Board of Electricity �� �'
1827 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 -
(651) 642-0800 www.electricity.state.mn.us ����
Apt. Bldg. Other: New Addn
Farm Remod Repair
Air Conditioner �Htg. Equip. I I Water Htr. I I Load Mgmt. I Other:
Dryer Range Elec. Heat Temp. Service
"X" above fhe work covered by this request. Enter remarks in this space and on the back of the white copy
1�b Gl au� �51 - 77 7- 78��5
Calculate Inspection Fee - This Inspection Reques► will noi 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 kom validafion date prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf � _ ` Rou h-in ins fion r uired?
Q� _/^!l g pec eq ❑ Yes Inspection Ofher Than Rough-In: ❑ Ready Now I Call
0 \,J`� You musf call fhe inspector when ready Date Ready:
I, �4icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
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