HomeMy WebLinkAbout07080194 ApplicationitN OF CAq
i,"Y.Tx%h,A`( (' - City of Carmd l Clay Township
-tl i' APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE r
FAY
CONTRACTOR ` `
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INFORMATION: Street Addre s city State Zip
' NAME CONTACFPHONE:
APPLICANT \
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INFORMATION: Property Owner Contractor
(or agent) OR Representative
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE: I
PROPERTY -l9v
OWNER
INFORMATION: srRE "'RESs: city state ZIP
`? `a W • Cs?,'?.._.. '? ?(-- Vicar r?.2? ?-?'t t-t b '\3 .
STREET ADDRESS (INSPECTION LOCATION): City State Zip
INSPECTION '-? WoOAS >??? zL c?? ?LL?
INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
TYPE OF IMPROVEMENT: MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?? /
O UPGRADE SERVICE: From to Q YES C? /NO
D UPGRADE PANEL BOARD(S) 3
Number of NEW CIRCUITS: I
11
D ADDITION, ALTERATION, REMODEL, or REPAIR TO
LPN EXISTING ELECTRICAL DISTRIBUION SYSTEM
j/NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
D ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
D CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMREETE AND ACCURATE.
Signature
PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach mar) of inspection location)
w a f JA \.. 5 4\' 5A tea` W 2CS? pz& \
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:PerMits/F0rMS1E1eCtri[a1 AppllCation Apr 2007