HomeMy WebLinkAbout07080196 Application,e? /?;'fqv G /X6
NAME PHONE FAX
CONTRACTOR L'V\- Ueorc'c
INFORMATION: Street address city State zip
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NAME CONTACT PHONE:
APPLICANT
INFORMATION: Property Owner Contractor
(or agent) OR Representative
1
TYPE of WORK: RESIDENTIAL: IZ- COMMERCIAL:
' PROPERTY OWNER NAME(S): PHONE:
PROPERTY
OWNER
INFORMATION
: srREET
ADDRESS:
cy sate IZp
91C6
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STREET ADDRESS (INSPEMON LOCATION):
IZIp
Cltr State
INSPECTION
INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
O UPGRADE SERVICE: From to
O UPGRADE PANEL BOARD(S)
O ADDITION, ALTERATION, REMODEL, or REPAIR TO
AN STING ELECTRICAL DISTRIBUION SYSTEM
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
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
O YES Q NO
Number of NEW CIRCUITS: 3
Number of METERS: I
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS RM IS C ND ACCURATE.
Signature
LQ,..-r ? LQwI.^r-nr '? I Z31 J-1
PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach r
2 r? o A?rl? M?? tzr e c? Pe4QSvvo` 3
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
City of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
Q
S:Pemits/Fonns/Eiectrtcal Appllutlon Apr 2007