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REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Apt. Bldg. Other: New
Farm Remc
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Repair
Air Condifioner Hig. Equip. Water Htr. Load Mgmf. Ofher:
Dryer Range Elec. Heat Temp. Service
"X" above tlie work covered by this request. Enter remarks in this space and on the back of the white copy onl
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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. o_
OFFlCE USE ONLY This rpueaf void 18 months from validafion date printed in fhis box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes No Inspection Other Than Rough-In: ❑ Ready Now Will Call
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I,�licensed contractor ❑ company ❑ owner hereby request inspection of the above elechical work at:
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