P - 82177REQUEST FOR ELECTRICAL INSPECTION ��
U-���-13 2� Minnesota State Board of Electricity `3
1821 Universiry Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993 .
� (651) 642-0800 www.electricity.state.mn.us '_�'
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Industrial � �Farm ��nn ..... Q�. ,.�.nain � �Remod I IRepair
I Dryer I I Range I I Elec. Heat I I Temp. Service I I
"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 Request will not e a�cc�ep�t�e wit out the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Requesf Date � Rough-in inspection required� ❑ Yes �fJo Inspection Other Than RougMn: �ady Now ❑ Will Call
�— _ 0 You must call the inspector when ready Date Ready:
I,�censed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job Address (Sheet, Box, or Roufe No.) City Zip Code
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Section No. Township Name or No. Bpcgidsb. 'fir�dlT. ounty
Occupant
Power
Phone No.
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my'1�6�e✓ V(J .�J Confracfor License No. Masfer Lic. No. �Planf Elecf. Only�
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Company or Owner Performing Insfallafion_ � _� , h^__
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:tor, m y ne erfor g Ins Phone Number
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY