HomeMy WebLinkAbout07110140 ApplicationCity of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
NAME PHONE FAX
CONTRACTOR ?
S c-Zro 710 -07,25 N A
INFORMATION: Street Address city State zip
7y9 E 1N cs I?? 114,24(0
NAME CONTACT PHONE:
APPLICANT GdJ LEST S/ 7 710 - 0
INFORMATION: Property Owner
OR Contractor
tative
Re
(or agent) presen
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY
E S G
o
OWNER
INFORMATION: STREETADDRESS: city state Zip
6 4?SD L C-C //I 2. =Q L s -L o 79
STREET ADDRESS (INSPECTION LOCATION): City State Zip
INSPECTION 7 _
??
`
INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
a UPGRADE SERVICE: From to
iE, UPGRADE PANEL BOARD(S)
O ADDITION, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
21r NEW METER SERVICE (i.e. Fountain in pond;
Subdivision street or signage fighting; Installation of
new utility services for an area)
ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
CD CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
O YES ? NO
Number of NEW CIRCUITS: 5
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
Signature
/LZ 7- 0
PRINT DATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach may of inspection location)
SLLAL E GREFI.) SU/?I? t/z --N
SN /A-1 V
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:PemiLs/Form,slElectrial Application Apr 2007