P - 82518�-0�3-373 �
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REQUEST FOR ELECTRICAL INSPECTION `��°"- •.
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:
Commercial Industrial Farm
Air Conditioner Htg. Equip. Wafer Hir. Load Mgmt. Ofher:
Dryer Range Elec. Heaf Temp. Service
"X" above the work covered by this request. Enter remarks in this space and on
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Repair
of the white copy only.
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.
OFFICE USE ONIY This requesf void 18 monihs From validation date prinfed in this box.
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PLEASE PRINT O TYPE
Request Dafe Rough-in inspection required? ❑ Yes o Inspection Other Than Rough-In: eady Now ❑ Will Call
� .� 3� O t7 You musf call fhe inspecfor when ready Dafe Ready: 6,�3/ � p
I�ensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Streef, Box o`Route No.) � Cily r / Zip Code ��
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Seciion No. Township Nam r o. R No. Fire No. CounN
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Power
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mpany Name
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or, Company or Owner I
Phone No.
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Address
Conkac r License No. Masfer L
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STATE BOARD C� SEE INSTRUCTIONS ON BACK OF YELLOW COPY