P - 82169REQUEST FOR ELECTRICAL INSPECTION
l.d i 9 3 7- 8 2 4� Minnesota State Board of Electricity ��i s
1821 University Avenue Suite 5-12$ Saint Paul, Minnesota 55104-2993 ��r
(651) 642-0800 www.electricity.state.mn.us "��
"X" above the work
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Calculaie Inspection Fee - This Inspection Request will not be accepted without the correct tee:
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONIY This request void 18 months kom validation dafe prinfed in fhis box.
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PLEASE PRINT OR TYPE
Requesf te Rough-in inspection required? ❑ Yes o Inspecfion Ofher Than Rough-In: ❑ Ready Now ill Call
You must call the inspedar whe� ready Date Ready:
I, licensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Job�dress (Sheel, Box, or Route No1 y �, � City � � r Zip Co �� ;__
No. I Townshio Name or
Occupant � 0 � � f �/ �� � � �" /� , _ Phone o. � r
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HT rpany Nw'a^ E, C� '!r V V v 1 I Coniracf r'�c/en_� s�e N7o;
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Installafion)
or Owner
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STATE BOARD COPY SEE INSTRUCTIONS ON BACK OF YELLOW COPY