P - 82607REQUEST FOR ELECTRICAL INSPECTION ��
U � � � � � (� � (� � Minnesota State Board of Electricity a
U �� 1821 University Avenue Suite 5-128, Saint Paul, Minneso[a 55104-2993 ����`�����
` (651) 642-0800 www.electricity.state.mn.us `�.�r=�"
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
ir C i er Htg. Equip. Water Hir. 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 Inspeciion 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 from validafion date printed in this box.
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PLEASE PRINT OR TYPE
Reque at Rou h-in ins ection re uired?
9 p q ❑ Yes Inspection Other Than gh-In: y Now ❑ Will Call
You musf call fhe inspector when ready Date Ready: '
1, �ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
1o�Qddress (Street, Box, or ute No.) City • Zip Code
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L o n �.P/t � .
Section No. Township Name or No. Range No. Fire No. County
Occup9ff}� � Phone No.
f � 1
S..CS-
Supplier
rontracfor / Company Name Confractor License
� �C� � Q r _F�► � �, (:b�
I res (Contractor, ompany o Owner Performing Insfallafion)
l� l� c� f� I�-�-�,-, 5�-- I�C—
�gnafure (Confractor, pany df Owne erforming Installation)
-12 5/1999 ,
STATE BOARD COPY
Master Lic. No. �Plant Elect. Only)
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SEE INSTRUCTIONS ON BACK OF VELLOW CAVv