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Commerciol Indusirial
REQUEST FOR ELECTRICAL INSPECT�ON
Minnesota State Board of Electricity
1621 UniversiTy Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Apt. Bldg. Other: �.� /� Ne�
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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 Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
THIS INSTALLATIOIY MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MOMTHS.
OFFICE USE ONLY This req�est void 18 months from validation date printed in ihis box.
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PLEASE PRINT OR TYPE
Request �fe Rough-in inspection required$ No Inspection Olher Than Rough-In: ❑ Ready N Will Call
�� � 6 You must call fhe inspecfor whe ready Dafe Ready: . �
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
10�dress �Sheet, Box, r R��No.� ��� City Zip Code
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SecTion No. Township Name or No. Range No. fire No. County � �
Occu nt
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Power Supplier I
Electrical Conhac r / Compan�e
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Mailing Address �Confractor, Co pany or ner P rfc
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Authorized $jgnature �Contracior, Compony or Owner
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��� STATE BOARD COPY
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Phone No.
1-78 - I3.1'v
��� Master Lic. No. (Plant Elect. Only)
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY