HomeMy WebLinkAbout06010156-Application
City of Carmel/Clay Township v/L,ft}N,
APPLICATION FOR ELECTRICALrNSPECTION
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NAME
CONTRACTOR ELEC Ie-
INFORMATION:
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NAME
APPLICANT k {6 lr
INFORMATION: . Property Owner
(or agent) OR
PHONE
FAX
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t;'\.(J - 9366
City
State
Zip
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CONTACT PHONE:
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Contractor
Representative
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TYPE of WORK:
RESIDENTIAL: \(
COMMERGAL:
PROPERTY OWNER NAME(S):
PHONE:
PROPERTY
OWNER
INFORMATION:
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Zip
STREET ADDRESS: aty
State
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STREET ADDRESS (INSPECTION LOCATION):
City
State
Zip
INSPECTION
INFORMATION:
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DATE OF INSPECTION:
TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
o UPGRADE SERVICE: From
to
DYES
~ 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:
'R
NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM ISr:;; ACCURATE.
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Signature
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
PRINT
DAle
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach maD of insDection location)
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FEES: $Jl6.25'for Commercial Inspections; $ 53.50 for Residential Inspections
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S:Permits/Forms/Electrical App tlon Oct 2003
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