P - 80268���U-895-648 �
"X" above the work
REQUEST FOR ELECTRICAL INSPECTION �
Minnesota State Board of Electricity
1821 Universiry Avenue Suite 5-728, Saint Paul, Minnesota 55104-2993 = -
(651) 642-0800 www.electricity.state.mn.us "��
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Calculate Inspeciion Fee - This Inspeciion Reques�
be accep�ed without the correc► fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS. �
OFFICE USE ONLY This requesf void 18 months from validafion dafe printed in fhis box.
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PLEASE PRINT OR PE
Requ sf Date Rough-in inspection required$ ❑ Yes ❑ No Inspection Other Than Rough-In: Ready Now ❑ Will Call
t`/� �� �� You musf call fhe inspector when ready Date Ready: .
I, icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo A dress (Sheet, Box, or Route N.� Ci Zip Code
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Secfion No. Township Nam or R nge . Fire No. County
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ELECTRIC. INC.
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Contracfor license No. Masfer Lic. No. (Plant Elecf. Only)
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SEE INSTRUCTIONS ON BACK OF YELLOW COPY