HomeMy WebLinkAbout06070057 Application
'f0Vwul- ~ ~ tJ~ () 1!zJS1
City of Carmel/ Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
~J.-t7f.'
NAME
PHONE
FAX
CONTRACTOR
INFORMATION: Street Address
APPLICANT
INFORMATION:
TYPE of WORK:
PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
6,;J-OJv"'-
Zip
Oty
State
/:J3{',j' &-. 5vit/ICr,<7:j/",...v /1<.,,- :::z-,.;..@",,~~t-...7
:::e;..v""A/~ '/,!.;l 5"}'
NAME
CONTACT PHONE:
/~
Property Owner
(or agent)
v
Contractor
Representative
.--
L, _a'_ '/u'7TL-t.;
OR
RESIDENTIAL:
~
COMMERQAL:
PROPERlY OWNER NAME(S):
PHONE:
:>
STREET ADDRESS (INSPECTION LOCATION):
. .2<7 N. mU~<hA~v' $.< .
STREET ADDRESS (INSPECTION LOCATION):
;;"':5""J 3 >'7
::t
State lip
City
~N/
Oty
-.-
",tL'~
State
("l,-.t"L- :z-......~N/ve<--
TIME OF INSPECTION:
,)~-e
DATE OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
o UPGRADE SERVICE: From
to
DYES
o NO
o UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
.~
Number of NEW CIRCUITS:
Number of METERS: I
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AN CURATE.
NEW METER SERVICE (I.e, Fountain in pond;
Subdivision street or slgnage lighting; Installation of
new utliity services for an area)
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
,.2s( CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
Signature"
(;:Lbt7r/ c. f?/ff
PRINT
~k
DA
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
<') 15(' _ j!7'/~rl.-e.- c;,b:~..7'
.:ES: $
.llts/Forms/Electrical Application Oct 2003
for CommerciallnspectionSi .$-5<<50 for Residential Inspections