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FOB #
Application Number
Tax/County

DBA

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DBA

Address 1

Address 2

City

State

Zip Code

Phone #

Application Number:

FOB#:

Date:

Owner:

Occupant:

City, Town or Village:

County:

Location/Address:

Section, Block & Lot:

Occupied As:

Application for:

Or:

Building:

Utility Company:

Meter #:

Service Request #:

Permit #:

Electrician:

Work Area:

Special Instructions:

Rough Wiring Information:

# of RW Switches:

# of RW receptacle outlets:

# of RW luminairs:

# of smoke alarms:

# of Vent Fans:

# of Dryer Receptacles:

# of Range Receptacles:

# of Water Pumps:

# of Water Heaters:

# of Wall Ovens:

# of Dishwashers:

# of Garbage Disposals:

# of Cooktops:

Wiring and Controls for burner:

AMP. Service:

Other Equipment:

Fee Paid By:

Fee Remitted: $

Check/MO #:

Fee:

Red Tag Notice? NOTES:

Final wiring/service information:

# of Switches:

# of DUP Receptacles:

# of GFI protected DUP receptacles:

# of floor receptacles:

# of Luminairs:

# of Smoke Alarms:

# of smoke/carbon alarms:

# of Paddle Fans:

# of paddle fans with lights:

# of vent fans:

# of vent fans with lights:

# of AFCI Circuits:

# of H.R. Ventilators:

# of Dryer Receptacles:

# of A/C Receptacles:

# of Range Receptacles:

# of H.V.A.C. units:

# of Water Pumps:

# of Water Heaters:

# of Wall Ovens:

# of Dishwashers:

# of Garbage Disposals:

# of Cook Tops:

Wiring & Controls for burner:

Electric Heat:

AMP. Service:

AMP. Service #2:

AMP. Service #3:

Size Service Conductors:

Other Notes:

Progress?

Certifications:

Service date:

Rough Wire Date:

Letter of Approval date:

Interim Letter of Approval Date:

Certificate Date:

Notified contractor date:

Notified owner date:

Notified municipal date:

Notified utility date:

Cut In Card Temp #:

Cut In Card Temp Date:

Cut In Card Final #:

Cut In Card Final Date:

Inspector Signature:

Finalize Application Now?