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REQUEST FOR ELECTRICAL INSPECTION `�°'E�
Minnesota State Board of Electricity
1821 UniversiTy Avenue Suite 5-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us
Mgmt. Other: �
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e the work covered by this request. Enter remarks in this space and on the back of the white copy only.
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Colculate lnspection fee - This Inspection Request will not be accepted without the correct fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED W�THIN 18 MONTHS.
OF'flCE USE ONLY ihis request void 18 months from validation date piinfed in fhis box.
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Requesf ate / Rough-in inspeclion required$ Yes ❑ No Inspection Other Than Rough-In: ❑ Ready Now Will Call
DYou must call the inspecror when ready Dofe Ready:
I,�censed contractor �'�ampa4ty�� owner hereby reque ' ivrtb#-t6e`bove electrical work at:
Box, or Route No. � U
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iship Name or No. Range No.
(Conhacfor, Company or
Zip Code
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Phare No.
Moster Lic. No. (Plant E
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Phone Number
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2 5/1999 STATE BOARD COP SEE INSTRl1CT10NS AN BACK OF YELLOW COpV