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City of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE FAX
CONTRACTOR Je5-7, (3!l7 oTW; 9 y5/
INFORMATION: StreetACC:ess Cie/ State Zip
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NAME CONTACT PHONE:
APPLICANT ?r•L?? r' ?''? C5'17] X1.Z- $77s-1
INFORMATION: Property Owner .? Contractor
(or agent) OR Representative
TYPE of WORK: RESIDENTIAL: COMMERCIAL: l/
PROPERTY OWNER NAME(S): PHONE:
PROPERTY
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OWN
INFORMATION: srREET ADDRESS City State Zip
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STREET ADDRESS (INSPEMON LOCATION): city State Zip
INSPECTION
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INFORMATION:
DATE OF INSPECTION: C?
6? TIME OF INSPECTION:
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TYPE OF IMPROVEMENT:
D UPGRADE SERVICE: From to
D UPGRADE PANEL BOARD(S) [AFCI BREAKERS REQUIRED]
O ADDITION, ALTERATION, REMODEL, or REPAIR TO
AN EXISTING ELECTRICAL DISTRIBUION SYSTEM
D 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)
D CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
COMMENTS or FURTHER LOCATION CLARIFICA7
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
O YES O NO
Number of NEW CIRCUITS:
Number of METERS: I
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE:
Signature
PRINT DAT??
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FEES: $ACZ for Commercial Inspections; $ for Residential Inspections
S:Ferrrits/Forms/Electrifal Application Oct 2003