HomeMy WebLinkAbout07110078 Application"v OF Cqq.F\ //VD
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City of Girmell Clay Township
( APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE FAX
CONTRACTOR 9,;r CLGCi/s 317 ?6r? 3 ZA9-
INFORMATION: Street Addresss city state 2'p
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NAME cATAcr PHONE: I
APPLICANT G "eT C ?, rT 7 ?<? 9y?
INFORMATION: proper Contractor
(or agent) OR Representative L.
TYPE of WORK: RESIDENTIAL:
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COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY ?T>
OWNER
INFORMATION: STREET ADDRESS: city state zip
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STREET ADDRESS (INSPECTION LOCATION): - City State Zip
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INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
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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
O 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
CD YES O NO
Number of NEW CIRCUITS:
Number of METERS: -1
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
Signature
PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:Perrn1WFoms/E1ectrica1 AppllcaUon Apr 2007