HomeMy WebLinkAbout07090012 ApplicationCity of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
NAME PHONE FAX
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INFORMATION: street Address CRY State ZIP
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NAME - CONTACT PHONE: 7
APPLICANT ! 4er -312- r -?
INFORMATION: Property Owner Contractor
(or agent) OR Representative
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY C 7( 7- 3?`1 - QSYi S-
OWNER
INFORMATION: SrREEr ADDRESS: city state ZIP
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t/ W 07 7
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STREET ADDRESS (INSPEMON LOCATION): City State ZIP
INSPECTION
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
VNEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage lighting; Installation of
new utility services for an area)
? YES ? NO
Number of NEW CIRCUITS: J
Number of METERS: r
I CERTIFY THAT THE INFORMATION CONTAINED
ON//yes FORM IS COWLETE AND ACCURATE.
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O ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
O CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
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FEES: $ 104.00 for Commercial Inspections; $ S7.S0 for Residential Inspections
S:Pe"IWFoMS1EIeCWa1 Application Apr 2007