P - 82441�-�51-296 �
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
7821 University Avenue Suite S-128, Saint Paul, Minnesota 55704-2993
(651) 642-OS00 www.electricity.state.mn.us
Home Duplex Apt. Bldg. Other: �
Commercial Industrial Farm Remod
Air Condifioner Hig. Equip. Water Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. $ervice
"X" above the work covered by this request. Enter remarks in this space and on the back of the white copy
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Calculate Inspection Fee - This Inspection Request will not be accep►ed without the correct fee:
Repair
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Dafe Rough-in inspecfion required$ �s ❑ No Inspection Ofher Than Rovgh-In: ❑ Ready Now ill Call
9� � You must call the inspecfor when ready Date Reody: �
I, �censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: