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City of Carmel /,Clay Township y APPLICATION FOR ELECTRICAL INSPECTION
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NAME PHONE FAX
CONTRACTOR -" G GG'"C7i i? / 7 (317
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INFORMATION: street Address aty state zip
X3,08 L 5?•c??P•t??tr,,/ vc. t?.,o.? l.5 ????/••g• ?, y6:?5y
NAME C ACT PHONE:
APPLICANT L?f. T //r. T i
INFORMATION: Property Owner Contractor
(or agent) OR Representative G
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(5): PHONE:
PROPERTY Tt
OWNER
INFORMATION: STREET ADDRESS: aty state vP
7 /,Pee
,49 `r ei .A. v L 3 ? dL
STREET ADDRESS (INSPECTION LOCATION): CRy state BP
INSPECTION
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A? rn 1? .-
INFORMATION:
OF INSPECTION; , TIME OF INSPECTION:
TYPE OF IMPROVEMNf .
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
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.
PRINT DATE
COMMENTS or FURT4E;t LOCATION CLARIFICATION: (Please attach map of inspection location)
FEE$: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
L?e_74
2007