P - 82062' REQUEST FOR ELECTRICAL INSPECTION -
��� ����� 7 � Minnesota State Board of Electricity a
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993 ���`
(651) 642-0800 www.electricity.state.mn.us "�'
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Fee - This Inspection Request
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;epted without the co�rect iee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
�y — i OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE
Request D te � �( Rough-in inspection required? ❑ Yes o Inspection Other jhq� Rough-In• Read N w❑ Will all
� �'UU You must call the inspecror when ready Dafe Ready: J�/ �`/� �
I licensed contractor ❑ company ❑ owner hereby request inspection of the above elecfrical work at:
Job Address (Shee�g x, or Roufe No.� City�' Zip Code
'�3S K J lf �YP_ r',�IPYYG� t� I'I�JG� L���
or No. � Range No. � Fire No.
Occupant� / i/
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Supplier a � � � �
:al Conirador / Company Nam_�
or
STATE
Phone No. �
7l� 3 �7�-9raa-�
No.
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY