HomeMy WebLinkAbout07010092 Application
"City of Carmel! Clay Township
APPLICATION FOR ELECTRICAL INSPECTION,
1107-
NAME
PHONE
FAX
CONTRACTOR
INFORMATION: Street Address
~ro/'
State
Zip
..-r:
~~ Y6Z"'-7
APPLICANT
INFORMATION:
'5/7-,&;!-
I
t
NAME
.. U-CV r,
Property Owner .../
(or agent) ~
OR
Contractor
Representative bA.~~ -;t;;:'/r/e:.
--"'-" COMMERCIAl:---'~-' -, . -....'
TYP!= of WORK:. ...
'RESIDENTIAL:
PROPERTY OWNER NAME(S):
PHONE:
PROPERTY
OWNER
INFORMATION:
5/5C- '
STREET ADDRESS:
City
State
Zip I
f't:z,"L-
Zip'
:<71 U// 5/idt' 7'
STREET ADDRESS (INSPECT10N LOCATION):
--=- ~v4- 'Qt..-,
,-r: ....r....'-::
State
t
!~
INSPECTION
INFORMATION: .
//?'t/L
TIME OF INSPECTION:
"', 7/"",
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
TYPE OF IMPROVEMENT:
o UPGRADE SERVICE: From
to
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
o NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
,
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE. I
o ROW SIGNAL, SENSOR, MONITOR (Le. Traffic Light)
~ CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE . ,
LOCATION CLARIFICATION: (Please attach maD of insDection location)
&, ?,(,,.,..,f C,'/;, 77
/,/ "'--,;7
DAlE
PRINT
FEES: $ 100.00 for Commercial Inspections; $ 55.50 for Residential Inspections
S:Permits/FormsjElectricar Application Apr 2006