HomeMy WebLinkAbout06030086 Application
City of Carmel! Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
()603 m~~
NAME
CONTRACTOR
INFORMATION: Street Address
APPLICANT
INFORMATION: Property Owner
(or agent)
TYPE of WORK:
RESIDENTIAL:
PROPERTY OWNER NAME(S):
PROPERTY
OWNER
INFORMATION:
\ ~e
S1REET ADDRESS (INSPECT10N LOCATION):
INSPECTION
INFORMATION:
OR
PHONE FAX
3 -0 511 - 03h'-/'
City State Zip
II Q. r-me. IN I;03a
, CONTACT PHONE:
Contractor
Representative
COMMERCIAL:
PHONE:
5
City State Zip
'll
City State Zip
, 'IN
S.
TIME OF INSPECTION:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
0 YES 0 NO
DATE OF INSPECTION:
TYPE OF IMPROVEMENT:
0'" UPGRADE SERVICE: From 100 A to 8,()nA
o UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DlSTRIBUION SYSTEM
o NEW MffiR SERVICE (i,e, Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
Number of NEW CIRCUITS:
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
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Signature 1 ()./ r . I
c; jp,vl'/ A lIen. I I tf 5 :\-10 ~Ofo
PRINT DATE i
.
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location) .
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I\\'iS \c, 0.,'" D\lP\'"\l\~(\d 'Sl>n\'\r'e *,C'l.~ ~,\ \ ~a.J..U ~A.9 \'~ms 'ft\o(n1d..1 .
r Commercial Inspections; $ 53.50 for Residential Inspections
s:permlts/Form~/Ele
n Oct 2003