HomeMy WebLinkAbout07040201 Application
City of Carmel! Clay Township
APPLICATION FOR ELECTRICAL INSPECTIOj
it 01 0 Y D 20 I '
CONTRACTOR
I N FORMATION: S'reetAddre55
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PHONE
FAX
~n~s
City
State
'\
NAME
CONTACT PHONE:
APPLICANT
INFORMATION: Property Owner
(or agent)
('J
OR
TYPE of WORK:
RESIDENTIAL:
COMMERaA~: c.--'
PROPERT'( OWNER:NAME(S):
PHONE:
PROPERTY
OWNER
INFORMATION:
w.
STREET ADDRESS:
City
State
,
Zip
. I
1...{"1 <I.
~
INSPECTION
INFORMATION:
0(, oJ-
DATE OF INSPECTION:
,
State Zip
3:\0 402-80 I
TI E OF INSPECTION: / Z ~ ~
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
STREET AODRESS (INSPECTION LOCATION):
2-
TYPE OF IMPROVEMENT: revtf
Do&.JN Gt'kZE
~ UPCRAD[ SERVICE: From~ to 26{)
DYES
o NO
o UPGRADE PANEL BOARD(S)
o ADDmON, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
Number of NEW CIRCUITS:
o ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED
ON~THI FORM IS COMPLETE AND ACCURATE)'
~~_,..... I
Signa . !
-C.\-\ IH.~ t.JJ L....~ "".-o..l ~-Qc,--o
PRINT DATE
o NEW METERSERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
o CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach maD of insDection location)
()/d -)pefJIAJal G~~ ..C;+~h'o-yt /7- /3 -()2 ~()Jf-()f~{)lg, 000
FEES: $ 104.00 for Commercial Inspections' $ 57.50 for Residential Inspections
S:Permlts/Form 1Electr~caLApp~atlon A~2007