P - 820040-967-469 �
Dryer
„X,� �
Industria)
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 '� �
mt
Remod ��Repair
Range I I Elec. Heat I I Temp. Service I
�rk�ered by this request. Enter remarks in this space and on the b ck of the white copy only.
f� L�L�'\
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 1S MONTHS. �_„
OFFICE USE ONLY This requesf void 18 months from validation dafe printed in fhis box.
I��{��{ii�l��»�i���ii�iii�i���i� �o,so �
* q 9 6 7 4 6 9 8� ��{c`t� �
PIEASE PRINT OR TYPE
Request ate Rou h-in ins tion r uired2 ❑ Yes
g pec eq �Als Inspection Other Than Rough-In: ❑ Ready Now �Will Call
7 /�j Q Yau must call the inspedw when ready Date Ready:
I, licensed contractor ❑ company ❑ ow�er hereby request inspection of the above electrical work at: