P - 78372REQUEST FOR ELECTRICAL INSPECTION
1�4 7 3 3 6 Minnesota Board of Electricity
� � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
� , (651) 642-0800 TTY/MRS 1-800-627-3529 �. _ .� : '
� www.electricitv.state.mn.us
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. — FOR OFFICE USE ONLY
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Request Date: Rough-in Inspection RequiredT ❑ Yes No Inspeclion Other Than Rough-In: ❑ Ready Now Will Call
Qq 0 p�� 3 You must call the inspector when ready! Date Ready:
I certify that I am the ❑ LICENSED CONTRACTOR ❑ COMPANY �OWNER and hereby request inspection of the electricai work at:
Job Address (Street, Box, or Route No.) Ciry Zip Code
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Section Township Range Fire No. County
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Occupant Phone
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Power supprer
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Electric.a-1 CeonVador / Company Name CoMractor License Number Master license Number
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Mailing Address (Contractor, Company or Owner Perfortning Installation)
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Authorized Signa (Co ctor, Com y or Own Performing Installation) Phone
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EB•00001A-13 7/1/2000 BOARD OF ELECTRICITV COPY WSTRUCTIONS ON BACK OF YELLOW COPY