HomeMy WebLinkAbout07080192 Application\?y or CAy,1 4 c'rRT'''RyFF•City of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
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-NAME PHONE FAX
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CONTRACTOR
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75 e - 6'J-7
INFORMATION: Street Address City state Zip
?ozQ .?r-' gk-DOL09
NAME CONTACT PHONE:
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APPLICANT
INFORMATION: Property Owner Contractor ?
(or agent) O R Representative
TYPE of WORK: RESIDENTIAL: ? COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY ?L?21 l7 EI n2 y
l ?3 ??? `J-1 S - l Ci!G
OWNER
INFORMATION: srREET AOORESS: ON State ZJp
5q i5 \,Q . CLAAr ,n A ?L) r . Cc`c4\, L ? l In o3
STREET ADDRESS (INSPECTION LOCATION):
-- City (? State Zip
INSPECTION VAAL W\aI ? i L1 G??S Crc?? QC3.ar4v-?( Cyr k?u3?
INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
O UPGRADE SERVICE: From to
O UPGRADE PANEL BOARD(S)
O ADDITION, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
C,2? 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
O YES I?O
Number of NEW CIRCUITS:
Number of METERS: I
I CERTIFY THAT THE INFORMATION CONTAINI
ON THI$r ORM IS COMP,L•ETE AND ACCURATE.
Signature
??c3. lbw rnor $? Z3l ?1
'PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach man of inspection location)
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FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:Pen-nWF0ms/E1edriC31P.pplkatlon Apr 2007