P - 82586REQUEST FOR ELECTRICAL INSPECTION
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� (/,��, � -" Minnesota State Board of Electricity ` ��
U�� �% "�-��� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us �'�;"�
Home Duplex Apt. Bldg. Other: New ddn
Commercial Industrial Farm Raraed Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above �he work covered by this request. tnter remarks fn thfs space and on the back ot t e white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without 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 fhis box.
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PLEASE PRINT OR TYPE
Request Da}e Rough-in inspecfion required? Yes
❑ No Inspection Ofher Than Rough-In: ❑ Ready Now � Will Call
�raa" �j! You must call the inspector when ready Date Ready:
I,�icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
a�wlt tlVAFiU GOPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY