application for electric permit

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500 Quartermaster Ct., Ste. 200; Jeffersonville, Ind. 47130. Phone: 812-285-6415 • Fax: 812-285-6468 www.cityofjeff.net. JOB INFORMATION. • Address: ...

APPLICATION FOR ELECTRIC PERMIT Building Commission 500 Quartermaster Ct., Ste. 200; Jeffersonville, Ind. 47130 Phone: 812-285-6415 • Fax: 812-285-6468 www.cityofjeff.net

Date : ____________________________ License # : ________________________

JOB INFORMATION • Address: _______________________________________________________________ _________ Lot # _________

• Is the site:

_______ Residential

_______ Commercial

_______ New

_______ Existing

• Give a description of the job being performed ___________________________________________________________ _________________________________________________________________________________________________

_____________ existing amps

_____________ ADDED amps

_____________ NEW amps

CONTRACTOR INFORMATION • Contractor: _________________________________________________________________________________

• Contractor address: ____________________________________ City ______________________ State _______

• Office phone: ____________________ Cell phone: ______________________

email: ___________________

PROPERTY INFORMATION • Property Owner: _________________________________________________________________________ • Address: ___________________________________________________ City _______________ State ________ • Phone: ___________________________________ E-mail: ___________________________________________

X ___________________________________________________________________________________________ (signature of license holder)

(date)

If you are submitting this application by mail, please include a self-addressed, stamped envelope for the permit to be mailed to you.

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