P - 78462REQUEST FOR ELECTRICAL INSPECTION
1�/� ���� 9 Q � Minnesota Board of Electricity -
`t � 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
s (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.state.mn.us
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Request Date: Rough-in Inspection Required? ❑ Yes I�NO Inspection Other Than RougMn: �Ready Now LJ VYII Call
/D ��� � 3 You must call the inspector when reedy! Date Ready. ,
I certiiy that I am the �LICENSED C�ITRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site Address (Strcet Box, or Route No.) City Zip Cade
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wer Supplier
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ntractor / Company Name
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iiling Address (CoMractor, ComDany or Owner
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Power Supplier Address
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Contractor License Number Master decbiaan or P
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�forming Installation)
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INS7RUC�q90N K OF YELLOW COPY � , BOARD OF ELECTRICT' COPV EB-00001Mt4 8.7. 20D2
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