Order Form for Electrical Inspection Stickers

Mr. Ken Godsey

April 4, 2012

Page 2

Electrical Inspection Supplies Request Application

EFFECTIVE January 1, 2014

Name ______

(Please Print) First Middle Initial Last

Electrical Inspector Certification #: ______Email Address: ______

Mailing Address: ______

City: ______State: _____ Zip Code: ______-- ______

County: ______Work Phone #: ______

Signature: ______Date: ______

Return completed application with check or money order payable to the Kentucky State Treasurer and send to Electrical Inspection Section to above address. PLEASE NOTE; SUPPLIES WILL NOT BE MAILED UPS. THERE ARE 100 CERTIFICATES AND 50 STICKERS PER PACKAGE. PACKAGES WILL NOT BE DIVIDED. Costs of packages include shipping and handling charges. Address all Request Applications to Ms. Kathy Harrod at the above address.

Field Inspection Reports (3pt NCR) / $7.50 per package (100) / _____Package(s) / Total $______
Certificate of Compliance (3pt NCR) / $17.00 per package (100) / _____Package(s) / Total $______
Code Violation(s) Sticker (Red 3”x6”) / $7.00 per package (50) / _____Package(s) / Total $______
Rough-in-Not Valid for Occupancy
(Red sticker) / $4.00 per package (50) / _____Package(s) / Total $______
Electrical Service Only (Yellow sticker) / $6.50 per package (50) / _____Package(s) / Total $______
Final For Occupancy (Green sticker) / $4.00 per package (50) / _____Package(s) / Total $______
Temporary Construction Service
(Green Sticker) / $4.00 per package (50) / _____Package(s) / Total $______

Total Amount Due: $ ______

(If you would like to pay by Credit Card please call the office)

Official Use Only: Date: ______

Check/Money Order # ______Amount: $ ______

Certificate Numbers ______to ______

Code Violation Stickers ______to ______

Not Valid For Occupancy ______to ______

Electrical Service Only ______to ______

Final for Occupancy ______to ______

Temporary Construction ______to ______

An Equal Opportunity Employer M/F/D