HomeMy WebLinkAbout07110128 ApplicationCity of Carmel/Clay Township Orl 110 12 g
k e APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE FAX
CONTRACTOR c 1? Wc. 3t? - z - Sfl - 3l?- -9 Ak&A15;-
INFORMATION: Street Addn city sera ZIP
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NAME CONTACT PHONE:
APPLICANT Ac)^ Ay
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INFORMATION: property 0- 1
wner Contractor
(or agent) OR Representative
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY $? f SF E- 3l -Cc32- v-7
OWNER
MEET EfT ADDRESS:
CRY was
ZIP
3030 Rcz- ?SEVELT ?E 1AJDtPo%1A Gtr /JAI ?(&Z/Qj
STREET ADDRESS (INSPECTION LOCATION): ON stare ZIP
INSPECTION (t'j
INFORMATION:
DATE OF INSPE ?
2 1 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
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
? YES X NO
Number of NEW CIRCUITS:
Number of METERS: '--
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLEY AND
Signature
- Ada-? Ii/7L?
PRINT TE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
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FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections