P - 78335REQUEST FOR ELECTRICAL INSPECTION
1 3 0 6 9 4 g ��nnesota Board c:�Electricity
� � 1821 University Avenue Suite S•128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-500-627-3529
www. electrici ty. state. mn. us
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Request Date: Rough-in Inspection Required? �'Yes ❑ Na Inspection Other Than Rough-Irr. ❑ Ready Now�tl7111 Call
_�S - You must call the inspedor when readyl Date Ready:
I certify that I am the �'LTCENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work ax
Job Address (Street, Bo� Route No.)
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Electncal ctor / Company Name Contracior License Number I Master
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Mailing Address (Contractor, Company or Owner Pe rforming In s t a l la t �on) �� '�
Author' d Signature actor, Company or Owner Pertortnmg mscai�anon� ••- �
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��"�� INSTRUC710NS ON BACK OF YELLOM� COPY
ev�nm��/2000 BOARD dF ELECTRICI'TV COPY