HomeMy WebLinkAbout07040169 Application
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City of Carmel/ Clay Township () 1 ~'Y ()' /0 ! I
APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE
CONTRACTOR
INFORMATION:
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NAME
APPLICANT l/ r'+ Vv< a
INFORMATION: Property Owner X
(or agent) OR
FAX
State
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Zip
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CONTACT PHONE:
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Contractor
Representative
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TYPE of WORK:
RESIDENTIAL: X
.
COMMERCIAL:
PROPERTY
OWNER
INFORMATION:
PROPERTY OWNER NAME(S):
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PHONE:
t LI C-t
JC/O- S
City State
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City State Zip
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STREET ADDRESS:
STREET ADDRESS (INSPECfION LOCATION):
INSPECTION
INFORMATION:
DATE OF INSPECTION:
TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
P-- UPGRADE SERVICE: From 100 to ZOO
o UPGRADE PANEL BOARD(S)
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DlSTRIBUION SYSTEM
DYES
.%J: NO
Number of NEW CIRCUITS:
Number of METERS: /
o NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Instaliation of
new utility services for an area)
I CERTIFY THAT THE INFORMATION CONTAINED
9~THIS FORM IS COMPLETE AND, ACCURAT~.
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Signature I
Vc. A' r' 1/'-1 G; -I t-<-, ell''! 7'/2 '(/07
PRINT DATE
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)
FEES: $ 104.00 for Commercial Inspectio
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; $ 57.50 for Residential Inspections
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S:Permlts/Forms/Etectrical Application Apr 2007