HomeMy WebLinkAbout06060120 Application
i
/
City of Carmel! Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
'* D~()70 /20
CONTRACTOR
INFORMATION:
s~ nCL\
PHONE
c:"'\5"tf'LLLtUf\ J-nc 20-8'1
, City
-iJl"Lv 1/?-8C,(f-2..I2.f
State Zip
NAME
Street Address
Sl'o1
). Us
L/O
APPLICANT
INFORMATION:
NAME
/V\;J1tle-\ M cG-\1U_
Property Owner
(or agent)
TYPE of WORK:
'.. "RESIDENTIAL:'" '
PROPERTY
OWNER
INFORMATION:
PROPERTY OWNER NAME(S):
C e\ C\c,,- 8<.tM\..5:
STREET ADDRESS:
-+ +
S~O 6. I?:..s S,
STREET ADDRESS (INSPECTION LOCATION):
INSPECTION I 0 ~ K J
INFORMATION: I Cl IOWY\e.
DATE OF INSPECTION:
TYPE OF IMPROVEMENT:
o UPGRADE SERVICE: From
to
o UPGRADE PANEL BOARD(S)
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
'~ NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Instaliation of
new utility services for an area)
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION:
'?/Clll shro,: + a-lku.he)
Fi'X
TN
'-/(0 I c/o
CONTACT PHONE:
OR
2.1 .. Be-I'-/: -OIL.o
Contractor
Representative 'j...
',.... -, COMMERCIAL: :......-
PHONE:
City
B<l ~ - 7'Wo /
State Zip
I
T tI "I0o:s 3
City State Zip
C(C.rm<-1 -:r 4(oOsZ-
TIME OF INSPECTION:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
DYES
o NO
Number of NEW CIRCUITS: I,
Number of METERS: I
,
I CERTIFY THAT THE INFORMATION CONTAINED
ON THI,S FORM ISfl?MPLETE AND ~CCURATE.
rn ~o_vf-m CJ:1jL-~_ j
SIgnature, _ ,
M IC.J~ c.6-hCc. 7-Z0-{)(o
PRINT DATE I
(Please attach maD of insDection lo~atiOn) ,
I
I
FEES: $ 100.00 for Commercial Inspections; $ 55.50 for Residential Inspections
S:Permlts/Forms/Electrical Application Apr 2006