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2. Date/Time
   Date/Time

   Date/Time
4. ELECTRICAL STAND ALONE PERMIT APPLICATION
6. Property Owner Last Name*
7. Property Owner First Name*
8. Property Owner Middle Initial
10. Address*
11. City*
12. State*
13. Zip Code*
15. Property Owner Phone Number*
16. Parcel ID Number*
17. Township*
19. Electrical Contractor Name/License #*
20. Electrical Contractor Email Address*
21. Electrical Contractor Phone #*
23. Electrical Contractor Address*
24. City*
25. State*
26. Zip Code*
28. Power Company
    -- Select One --Duke/ProgressHEMC
29. If Duke/Progress/Premiss #
31. Type of Improvement
    -- Select One --New ServiceChange of ServiceRewireTransfer Switch/GeneratorHVAC Service
32. If not listed/Other:
33. Use of Service
    -- Select One --ResidenceCommercial BuildingAccessory BuildingHeat PumpFence/Gate
34. If not listed/Other:
36. Service Entrance
    -- Select One --OverheadUnderground
37. Amperage of Service Main
38. Gas Line Contractor & License # (if needed)
40. Directions to the job:
42. Submitted By:*
43. It shall be the responsibility of the installer to make arrangements for required inspections and to insure the electrical inspector has access to the equipment.
45. By submitting this application I hereby certify that all information on this application is correct and all work will comply with the State Building Code and all other applicable State and local laws and ordinances and regulations. The Inspection Department will be notified of any changes in the approved plans and/or specifications for the project permitted herein.*

    1. I Agree
47. When our office receives your request, we will call for credit card payment.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

* indicates a required field