P - 82449REQUEST FOR ELECTRICAL INSPECTION �
U���- 615 [�l Minnesota State Board of Electricity
1821 University Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 �;
(651) 642-0800 www.electricity.state.mn.us '� '
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Co' ' ner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat 7emp. 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 Inspeciion Fee - This Inspection Requesi will not be accepted wiihout the correci fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
. OFFICE USE ONLY This request void 18 months from validation dafe prinfed in this box.
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PLEASE PRIMT OR TYPE
Requesf Dafe Rough-in inspection required? ❑ Yes No Inspection Other Than Rou h-In: Ready Now � Will Call
fa You musf call the inspecfor when ready Date Ready: 9' �D
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
J ddress �Sheet, Box, or Route No.) City �/ Zip Code
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Township N or No. � Range No.
Occupanf
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Power Supplier R .
�EI hical Conhactor / Company Name
u��r $1, ✓t �l�r�F-r � �
ailing Address (Confmcfor, Company or Owner Perf ming
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u orized Signature (Conhactor, Companv� �Cye\ra�u�e�ie
:B-00001A-12 5/1999 �
STATE BOARD COPY
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Phone No.
7G3 �- 7��
Contracto� License No.
No. (Planf
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY