HomeMy WebLinkAbout06050192 Application
City of Carmel/ Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
cJ~OS() / 9 L :
. '
NAME
PHONE
FAX
CONTRACTOR
INFORMATION:
DIetl
1Je.
357-(,166
Street Address
, City
'State
Zip
5&, 10 G'CeetJS\l\~IJ Mf: :LJdpl~
.INd
4(,219
APPLICANT
INFORMATION: Property Owner
(or agent)
s~
CONTACT PHONE:
3:57- fo 700
NAME
OR
Contractor
Representativef),n W
TYPE of WORK:
RESIDENTIAL: j(
COMMERCIAL:
PROPERTY OWNER NAME(S):
PHONE:
Q,oJ - ~354:
PROPERTY
OWNER
INFORMATION:
c
STREET ADDRESS:
City
State
Zip!
37~f.o E. Ca'Ci"\ L dv-
\
--P.bI
4l:,03
STREET ADDRESS (INSPEmoN LOCATION):
City
State
ZIPi
INSPECTION
INFORMATION:
TIM? ~ ~SP CTION:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
DATE OF INSPECTION,;- 3() '.:2tJ1J
TYPE OF IMPROVEMENT:
old /SeW
5t UPGRADE SERVICE: From ~ to f).~
DYES
o NO
o UPGRADE PANEL BOARD(S)
Number of NEW CIRCUITS:
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
Number of METERS:
I
(ll NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Instailation of
new utility services for an area)
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
amfilJY1'a O. rl1:0~.
Signature !
AA)1---~()1JY A. 1A1.11/s 01/20) b
PRINT DATE / '
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
I
,
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach maD of insDection location)
,
FEES: $ 100.00 for Commercial Inspections; $ 55.50 for Residentiallnspect;ions
S:Permits/Forms/Electrlcal Application Apr 2006