HomeMy WebLinkAbout06060108 Application
TYPE OF IMPROVEMENT:
CONTRACTOR
INFORMATION:
APPLICANT
INFORMATION:
TYPE of WORK:>-
PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
C;/Y.lJf Caffltel/ Clay 'Township r ~()fe Cfe () I () 8'
APPLICATION FOR ELECTRICAL INSPECTION
.:t1/ oC)
FAX
NAME
PHONE
kl-~\tt.\~ Gl-S)iUc.:n,..tc...
~n. 788'Z:'In
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~Il' 78"&'2,/10
D.L. '&,I>L.€>
Street Address J I A
u,on F. /ifWNhl f-tvc. SurrG C
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City
//0Dh!'
State
Zip
ft.i
t.f{,u, 3>
NAME I \
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CONTACT PHONE:
'3(7- &DfD' Z'1.\~
Property Owner
(or agent)
'/--
Contractor
Representative
OR
- .. RESIDENTIAl:--
COMMERpAt::-
-)(
PROPERTY OWNER NAME(S): . ~ PHONE:
Cs.....T'<.y t\\)MSS. ~ N(\J~~' r1,~.;T1JI;RStHP
STREIT ADDRESS: I City
't~L\() U--ISON 'F1\tJ\t: 15LI/b. ~t0WL.s.
: 3\7.MCo'2.'1.I8'
I
~are ~p
~,-J ~G,250
State
Zip
STREIT ADDRESS (INSPE~lN LOCATION): :
q3~ Yz.. 4%t /~ Avt.
DATE OF INSPECfION:
10
TIME OF,INSPECfION:
/ I
MOVING SERVICE FROM OV
TO UNDERGROUND?
J
DYES ! ~ NO
Number of ~EW CIRCUITS:
(
o UPGRADE SERVICE: From . to
o UPGRADE PANEL BOARD(S)
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
,
\
Number of METERS:
I
I CERTIFY THAT THE; INFORMATION CONTAINED
ON THIS FORM IS C<llMPLETE AND ACCURATE.
1{J~
Signa re t
-!Ll:M.I"" A. ~'L.\k-,,,-,......i 1/5/0{o
PRINT J DATE
tD--- NEW METER SERVICE (I.e. Fountain in pond; ;
Subdivision street or signage lighting; Installation of
new utility services for an area) I
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
I
o CONNECfION or RECONNECfION TO A RELOCATED
_ STRUCTURE
j .
COMMENTS or FURTHER LOCATION CLARIF~CATION: (Please attach maD of insDection location)
. . \ f 81'J .1+terv\5 (3r1~ {! M &-f1 B n ;
;1ikreu>+sr: 01-- 6FC ( 14ca~ .oN 8KL of ~ W4 Fa>1Z-
lAl.l!)'\CAP~ U(;.H'TrJ->b <!- HllIJt(( FoIL 'RR.\(,,(n<o.-J 't.%ffi^..... ;
100.00 for ommerciallnspectionsi $ 55.50 for R~sidentiallnspections
. ,
S:Permlts/Fonns/E
on Apr 2006
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