HomeMy WebLinkAbout07090043 Application41V OF Cqq??
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City of Carmel/Clay Township 7 J U
Y ; APPLICATION FOR ELECTRICAL INSPECTION
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NAM / PHONE • FAX
317-V41-o -4,117 887- a477
CONTRACTOR .
INFORMATION: Street Addrew city state Zip
7 33 ? e'4 Z3
NAME
e CONTACT PHONE:
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APPLICANT z
INFORMATION: Property Owner Contractor
(or agent) OR Representative V
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY r9.v LJr e--e/, ? ie o g 3r 7- 5- V- 311,00
OWNER
INFORMATION:
STREET ADDRESS: /
ory /state / zip
STREET ADDRESS (INSPECTION LOCATION): ZIP
State "
City
INSPECTION 1 a D 7 3 L //
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INFORMATION: -
DATE OF INSPECTION: • C. r ' TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
? UPGRADE SERVICE: From to
O UPGRADE PANEL BOARD(S)
O ADDITION, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
9/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)
? CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
? YES / NO
Number of NEW CIRCUITS:
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED',
ON THIS ORM IS COMPLETE AND ACCURATE.
Signature
`
5Go ! [ /-• ?,, /, 7
PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
T'.J.'_I - -r , 1•_,._ n _.I . .
FEES: $ 104.00 fo Commercial Inspections; $ 57.50 for Residential Inspections
::PennILS/Forms/EleC:rica on pr2007