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REQUEST FOR ELECTRICAL INSPECTION W
Minnesota State Boartl of ElectnciTy
7821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800 '�°' �
. O�her. New Q�ddn
Air Cond. Hig. Equip. Water Htr. Load Mgmt. Other.
Dryer Range Elec. Hea1 Temp. Service
"X" a t6e work rovered by Ihis requesG Enfer remarks in this space and on the back of N
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Calcula/e Inspecfion Fee - 7his Inspection Request will nof be oc<epfed wifhouf fhe rorrect �ee:
Other Fee N Service Entrance Size Fee # Circuits
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INSPECTOR'S USE ONLV
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THIS INSTALLATION MAY 8E ORDEREO DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. f
OFFCE USE ONLY ihls requesr void 16 monihs 6om mlidation dale prinled in ihis 6ox.
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Section No.
LEASE PRINT OR TYPE
Rooghin Inspenion required2 ❑ Ve Inspection Oiher ihon Roog w � Will Coll
� �You musY<allthe inspxiorwhen ready) Dale Ready:
coNmcior ❑ owner hereby request inspection of ihe above electrical work at:
. Box, ar Roure No.� Ci Zip Code
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nhip Nome or No. Range No. Flre No. C
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