P - 80338� REQUEST FOR ELECTRICAL INSPECTION �
�°���- 5 6 0 C� Minnesota State Board of Electricity �
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us
"X" above the work covered by this request. Enter remarks in this space and on the back of the white c
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Calculate Inspection Fee - This Inspection Request �Jill 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 monlhs 6om validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspection required� ❑ Yes ❑ No inspecfion Other Than Rough-In: Ready Now � Will Call
� 0� You must call the inspector when ready Date Ready:
I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
lob Addreu �Street, Box, or Route No.) � City � �, � Zip Code �
Powar
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or No. RanAe No. Fire No.
Name
Mailing Address (Conhactor, Company or Owner PerFo�ming In�` tion� �,'!
Phone No.
No.
, Company or Owner Performing InstallatiCfi� � Yhone Number
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STATE BOARD COPY SEE INSTRl1CTIONS ON BACK OF YELLOW CAPV