HomeMy WebLinkAbout07100064 Application-"City of CarmdlClay Township
APPLICATION FOR ELECTRICAL INSPECTION
NAME PHONE FAX
CONTRACTOR ,, cTirU 317 -
INFORMATION: Street address aty state ZAP
/236d' ?bsT ?vfli?s -ew? .4. -e- ??o c / y626-
NAME CONTACT PHONE:
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APPLICANT ,L6,tiT L"• 477- r 6.? >3
INFORMATION: Property Owner Contractor
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(or agent) OR Representative
TYPE of WORK:
RESIDENTIAL: y
COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY 1-7ti.r
OWNER
INFORMATION:
SWEET ADDRESS:
aty sari zip
Ja77 W Z ?? uL.s ?t/ e.? y62 s-9
STREET ADDRESS (INSPECTION LOCATION): City state Zip
INSPECTION'
INFORMATION:
DATE OF INSPECTION: TIME OF INSPECTION:
TYPE OF IMPROVEMENT:
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
D UPGRADE SERVICE: From to
D 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)
O CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
O YES O NO
Number of NEW CIRCUITS:
Number of METERS: /-
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE ?VD ACCURATE.
? 1
Signatvrre
PRINT ATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:Pe its/Forms/Electrical Application Apr 2007