P - 78872�„ REQUEST FOR ELECTRICAL INSPECTION
1 � �� � � � /� � Minnesota Board of Electricity �
J �+ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
°�� (651) 642-0800 TfY/MRS 1-800-627-3529
www.electricity.state.mn.us .,,m,
FOR OFFICE USE ONLY � � � /
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7 �� You must call the inspector when ready! Date Ready
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at:
Job Address (Street, Box, or Route No.) ��,
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Power Supplier Address
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Electriql ntractor / pany Name
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M'ling Address (CoMractor, Compan�or er Pertormin In
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Autho' Signature Contractor� Compen r pwner Pe ormi
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Contractor Lice�se Number Ma r License Number
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