HomeMy WebLinkAbout06090017 Application
City of Carmel/ Clay .Township
APPLICATION FOR ELECTRICAL INSPECTION
o 0 00/ I
PHONE FAX !
CONTRACTOR
INFORMATION:
APPLICANT
INFORMATION:
TYPE of WORK:
PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
Street Address
1;1.76.1' e. 5ourk;'dt'/A/ A'",~
NAME /?
c,L.-,/""r C. r",.,-r
Property Owner
(or agent)
sse-
. d. RESIDENTIAL: ..
PROPERTY OWNER NAME(S):
58C-
L. ~ <' ,,4~.oeL-
STREET ADDRESS:
/..R 7 ;1 .M/ /".a ~..-t-
STREET ADDRESS (INSPECTlON LOCATION):
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
o NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Instailation of
new utility services for an area)
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
W CONNECITON or RECONNECITON TO A RELOCATED
~ STRUCTURE ,
COMMENTS or FURTHER LOCATION CLARIFICATION:
S".dLo~ /fM- ;;::c. ~~$;T,,~
:J 17',f'6;(- '77.rY
City
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-
317-P~'d"'YS
State ZIp
,
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OR
CON.TACf PHONE: . I
( :117.-J ?6~-j1/~
Contractor L. '" <. ,,4J'~'--
Representa~jve
COMMERCIAL: ~.
PHONE:
(51?..J ;:2G.,- f'/f.5
oty
~M"l"'t'"
State
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I
ZJp
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City
State Zip
,II,,,,,,,,L ~;'/-- "/I/?5
TIME OF INSPECTION:
. (;J ()~
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
'.
DYES
o NO
Number of NEW CIRCUITS:
Number of METERS: I
,
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE ACCURATE.
g
Signature
(;/L:j",r C .;!?d'/"
PRINT
~~
OA i
!
I
(Please attach maD of insDection location)
.4/Z-'A/~ VI'/AA//6L-
,
./l/d~L 5 /d~ ,,/ J&-Pn/7'1t'!'y'" 'V.4C'C:-
(' L7".c/",.., v /:/~:;r'AJ/./'&." )
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FEES: $ 100.00 for Commercial Inspections; $ 55.50 for Residential Inspections
S:Permlts{Forms/Electrlcal Application Apr 2006