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REQUEST FOR ELECTRICAL INSPECTION —
� Minnesota State Board of Electricity ':3
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55 1 04-2993
(651) 642-0800 www.electricity.state.mn.us "ffi'
Farm Remod Repair
Air Conditioner Htg. Equip. Wafer Hfr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X„ above the work covered by this request. Enier remarks in this space ond on the back of the white copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted wi►hout 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
quesf Date Rough-in inspecfion required? Q�Yes �lo Inspecfion Other Than Rough-In: �❑ Ready Nowi�Will Call
�✓� 7 i�� You musf call the inspecfor when ready Dafe Ready:
licensed contractor ❑ company ❑ owner hereby request inspection of the above electricol work at:
Ireu �Sheet, Box, or Route No.) „ Ciry Zip Code
rvame or rvo.
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ompany Name
cfor, Company or Ownar Per
mhacfor, Company or ei
STATE BOARD
Phone No.
Conkacfor License Noi���. . � Masfer Lic. No.
SEE INSTRUCTIONS ON BACK OF YELLOW COPY