P - 82162REQUEST FOR ELECTRICAL INSPECTION ���
�1 � Q �� � � � � � Minnesota State Board of Electricity _
V �� 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 .
(651) 642-0800 www.electricity.state.mn.us "��
ome Duplex Apt. Bldg. Other: New Addn
mmercial� Industrial Farm Remod Repair
Air Con r Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the work covered by ihis request. Enier 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 be accepted withou► the correc► fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This request void 18 months from validation date prinfed in this box.
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PLEASE PRINT OR TYPE
Request Date_i/ Rough-i� inspection requ+red$ ❑ Yes o {nspection Olher Thon Rough-In: Ready Now � Wili Cail
3� You must ca�l the inspector when ready Qate Ready:
1, licensed contractor ❑ company ❑ owner hereby request inspection of the above electricai work at:
Job Addr ss $heef Box, or Ro e No.) City . Zip Code
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or No. ° � Range No. � fire No.
Occupant � //. /��� � lydne /. �e
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Power Supplie Addr
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Elect ' r tor f o any Na e Cont� or License No. Mas
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a� m�j A�d ress (Co%nt �ro�r, Company or Ow� Perfor '= tion� //
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TE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY