HomeMy WebLinkAbout04120067 Application
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"'( '" ~ ~ l City of Carmel! Clay Township .
\ ~", ) APPLICATION FOR ELECTRICAL INSPECTION
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CONTRACTOR
INFORMATION:
APPLICANT
INFORMATION:
TYPE of WORK:
, PROPERTY
OWNER
INFORMATION:
INSPECTION
INFORMATION:
NAME
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Street Address
FAX
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-'1(, 'IS
PHONE
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City
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-f'777
Zip
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State
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CONTACT PHONE:
NAME
5/7-75<' -77S~
Property Owner
(or agent)
Contractor
Representative /
OR
RESIDENTIAL:
COMMERCIAL:
/
.
PHONE:
39-/?f'
State
,
Zip
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,
Zll
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STREET ADDRESS (INSPECT10N LOCATION):
/ZY97 e~Nc,.dAc.?1:'
DATE OF INSPECTION: M
Oh
City
State
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~ TIME OF INSPECTION:
.-
I
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND? '
TYPE OF IMPROVEMENT:
o . UPGRADE SERVICE: From
to
9 NO
DYES
o UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
Number of NEW CIRCUITS:
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
Number of METERS:
I
W 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.
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SIgnature I
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PRINT DATE
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION:
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(Please attach maD of insDection location)
/
r Commercial Inspections; $
for Residential Inspections
S:PermltsjForms/Electrlcal App 2003