P - 82138REQUEST FOR ELECTRICAL INSPECTION �,
U d�,�� ��� Q� p � Minnesota State Board of Electricity �'
�' �� Q 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
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, (651) 642-0800 www.electricity.state.mn.us "�'•
"X" above the work covered by this request. Enter remarks in this space
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correcf fee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED !F NOT COMPLETED WITHIN 18 MONTHS,
� OFFICE USE ONLY This requesf void 18 monihs from validation dafe printed in this box.
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PLEASE PRINT R TYPE
que Dai Rough-in inspecfion required$ ❑ Yes o Inspection O�er Than�h-I dy N w❑ Will Call
You must cpll the inspector when ready Date Ready: ��
�licensed controctor ❑ company ❑ owner hereby request inspection of the above electrical work at:
� rlddress �Sfr�et, Box, or R�e No.J A� � /!1 i I C�ry.1i � t r Zip Code . I^. —
No. � Township Name or No. � Range No. � fire No. � Counly
a I Contractor License
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Insfallafion�
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� STATE
Phone No.
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