HomeMy WebLinkAbout04120066 Application
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City of Carmel/ Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
CONTRACTOR
INFORMATION:
APPLICANT
INFORMATION:
TYPE of WORK:
PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
PHONE
FAA
NAME
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Street Address
/51//7 S ~ 411~ ~r
NAME
/t:JAae./ 7J.tv/h
Property Owner
(or agent) OR
RESIDENTIAL:
/7- 7(, 7- '1"7;1
City State
&c:c~ .live Z,;'",sl/,'/I<:. ~
Zip
;~f77
CONTACT PHONE:
J/7-7SZ-77S'8
Contractor
Representative . Y
COMMERCIAL: ;../
PROPERTY OWNER NAME(S):
AtQft:. ,A,{fiuo,< J
STREET ADDRESS (INSPECT10N LOCATION): City
37- /1 f'r
PHONE:
State
Zip
3e:J3C) ~"$~(h~# ,4",<. ::z;;..I.I:tA.D ;,-1- .:://"'"
STREET ADDRESS (INSPECT10N LOCATION):
53/ 'OOQlle.tt~.
DATE OF INSPECTION: 11 .
or,
TYPE OF IMPROVEMENT:
o UPGRADE SERVICE: From
to
't2/,g
City
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Dee IS-J.I1
Zip
State
.:z;.; .
TIME OF INSPECTION:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
DYES
% NO
o UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
.If' NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation 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: (Please attach maD of insDection location)
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Number of NEW CIRCUITS:
Number of METERS: /
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
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Signature
~~c.c/ 7).~u/4
PRINT
/.2-/(1-11 ~
DATE'
: $ 93.50 f r Residential Inspections
5:Permits/Forms/Electric 2003
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