HomeMy WebLinkAbout08010051 ApplicationCity of Carmel/Clay Township
APPLICATION FOR ELECTRICAL INSPECTION
NAME PHONE FAX
CONTRACTOR
INFORMATION: Street Address city state zip
NAME CONTACT PHONE:
APPLICANT
INFORMATION: Property Owner Contractor
(or agent) OR Representative
TYPE of WORK: RESIDENTIAL: COMMERCIAL:
PROPERTY OWNER NAME(S): PHONE:
PROPERTY
L L, y i
13
OWNER
INFORMATION: STREET ADDRESS: City State Zip
STREET ADDRESS (INSPECTION LOCATION): City State ZIP
INSPECTION
INFORMATION:
DATE OF INSPECTION: f I I?
TIME OF INSPECTION: ? ,
Nu+?w :nom
TYPE OF IMPROVEMENT:
D UPGRADE SERVICE: From to
D UPGRADE PANEL BOARD(S)
Z??-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)
D ROW SIGNAL, SENSOR, MONITOR (i.e. Traffic Light)
D CONNECTION or RECONNECTION TO A RELOCATED
STRUCTURE
MOVING SERVICE FROM OVERHEAD
TO UNDERGROUND?
O YES Cf NO
Number of NEW CIRCUITS:
Number of METERS:
I CERTIFY THAT THE INFORMATION CONTAINED
ON THIS FORM IS COMPLETE AND ACCURATE.
I,A
Signature
L2 4- A ZI 7 /?e
PRINT ATE
COMMENTS or FURTHER LOCATION CLARIFICATION: (Please attach map of inspection location)
e- - . U,// A e_
FEES: $ 104.00 for Commercial Inspections; $ 57.50 for Residential Inspections
S:PermiWForms!Electncal Appllcation Apr 2007