HomeMy WebLinkAbout06030028-Application
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APPLICATION FORELECTRICA[;.
NAME
PHONE
FAX
/ 5~e?
NAME
~-
I
17-752-7752 317-76'1- 9'6 ~y
City State
CONTRACTOR
INFORMATION: Street Address
CONTAcr PHONE:
APPLICANT
INFORMATION:
17-7.J2. - 77.
OR
Contractor
Representative t/
TYPE of WORK:
RESIDENTIAL:
COMMERCIAL: V
PROPERrf OWNER NAME(S):
PHONE:
PROPERTY
OWNER
INFORMATION:
17-632-'i'tJ77~)t 58
CIty stale Zip
eve/I-
-
STREET ADDRESS (INSPECTION LOCATION):
City
State
f"t 2 /8
Zip
INSPECTION
INFORMATION:
3t20S-
TIME OF INSPECTION:
DATE OF INSPE
TYPE OF IMPROVEMENT:
OVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
o UPGRADE SERVICE: From
to
DYES
.ef NO
o UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
Number of NEW CIRCUITS:
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
Number of METERS: /
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
ON THIS FORM IS .COMPL
.lkr NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
o CONNECTION or RECONNECTION TOA RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach maD of insDection location)
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of- u- ~. (,-le (,).:D L- {NE-
Signature
A
r Commercial Inspections; $ 53.50 for Residential Inspections
2003 i1dlU'Yl M ye..ticl-]