P - 82043.
U-�27-0�9 �
REQUEST FOR ELECTRICAL INSPECTION �v�°'•E�
Minnesota State Board of Electricity �" � 3�
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 ��,,�
(651) 642-0800 www.electricity.state.mn.us ��S "�'�'"
Apt. Bldg. Other: New ddn
Farm Remod Repair
I Dryer I I Range ' I Elec. Heat I I7emp. Service I
"X" above the work covered by this reqvest. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request 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 monfhs 6om validafion dafe printed in }his box.
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PLEASE PRINT OR TYPE
iequesf ate Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-In: ❑ Ready Now ill Call
�a.� �� You musf call fhe inspecfor when ready Date Ready: �
I, � licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job �re-ss`�,treet Box or�Route N.) �� � C�ii�p I�` � � Zip Code
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Settion No. Township Name or No. Range No. Fire No. Coun���
Ottu n�a t_ _ �T Phone No.
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Power Su plier Address
�lA- „ � 27 :
Electrical Contmdor / Company Name Conhacror Lice�se No. Master Lic. No. �Wanf Elect. Only�
11IK-LYII BLBC'fKIC CQ� GA�12�fr
Mailing Addreu (Confractor, Company or Owner PerformingJnstollation)
123�aa B� t.e� F►aurk �1 va. GHA1lFLI lt. l!U 5�5�3ts 6�
Aufhorized ' ure �Conhactor, Company or er Peho ing sta ion) Pho b�
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E -12 1999 STATE BOA D COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY