P - 82455REQUEST FOR ELECTRICAL INSPECTION �
U!-8 6 2� 119 � Minnesota State Board of Electricity � �'
1821 UniversiTy Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
--� (651) 642-0800 www.electricity.state.mn.us " '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Indusirial Farm Remod Repair
Air Conditioner Hfg. Equip. Water Hfc Load Mgmt. Other.
Dryer Range Elec, Heaf 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 Inspection Reques► will noi be accepted without the correci fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�— � ^ OFFICE USE ONLY This requesf void 18 monfhs 6om validafion dafe prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date Rough-in inspection required? ❑ Yes Inspection Ofher Than Rough-In: ❑ Ready Now a I
��� v0 � You must call the inspector when ready Date Ready:
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at: