HomeMy WebLinkAbout07020046 Application
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City of Carmel/ Clay Township ~ 07 0200 4- (p
APPLICATION FOR ELECTRICAL INSPECTION
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NAME
Be-f' fner
PHONE
FAX
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CONTRACTOR
INFORMATION:
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3/7- 77J-76b3
Street Address
City
State
,
lip
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NAME
CONTACT PHONE:
APPLICANT .
INFORMATION:
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Property Owner
(or agent)
3(7- 773'-7hf.3
OR
Contractor
Representative
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TYPE of WORK:
RESIDENTIAL:
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COMMERCIAL:
PROPERlY OWNER NAME(S):
PHONE:
PROPERTY
OWNER
INFORMATION:
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STREET ADDRESS:
DATE OF INSPECTION:
City State Zip
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City State lip'
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INSPEqION
. INFORMATION:
STREET ADDRESS (INSPECTION LOCATION):
E OF INSPECTION:
TYPE OF IMPROVEMENT:
MO G SERVICE FROM OVERHEAD
UNDERGROUND?
o UPGRADE SERVICE: From
to
DYES
0' NO
o UPGRADE PANEL BOARD(S)
d ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
Number of NEW CIRCUITS: I
Number of METERS: )- D
o NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utiiity services for an area)
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
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6d. -03'-107
DATE I
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
Signature
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION:
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PRINT
(Please attach map of inspection location)
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FEES: $ 100.00 for Commercial Inspections $ 55.50 for Residential Inspection
S:Permlts/Forms/Electrical Application Apr 2006