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;APPRO
MENT DECISION APPLICATION FOR ELECTRICAL PERMITPERMIT#
TOWN OF SOUTH WIlVDSOR 5-7
BUILDING DEPARTMENT
1540 SULLIVAN AVENUE Bldg.Permit#
5�2 -,0'5 644-2511 ext. 230
Date B ing Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE �..,, � _ �
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS r1 �
APPLICANT PHONE#
N OWNER 1 `�
OW SF
OWNER ADDRESS ^'�^�
OWNER PHONE
C ESTIMATED COST$
IS THIS A CONTRACT COST? Yes ✓No
FEE ENCLOSED$
TYPE OF JOB:
�SOR'CO New Installation
-'jGteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? ❑ YE NO
RESIDENTIAL
❑BUSINESS CURRENT USE AND OCCUPANCY
❑ASSEMBLY
❑MERCANTILE FUTURE USE AND OCCUPANCY
❑EDUCATIONAL
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
❑STORAGE
❑GARAGE ADDRESS
❑MIXED USE
CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION/WIRING METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS
NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS REMOTE DISCONNECT REQUIRED? ❑YES ❑NO
NUMBER OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES NUMBER OF OUTLETS
NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
�►(`c 1 f1 �C. �
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
�\CA Ck i" �--
CONTRALTO LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT L4 g S DATE �` 7` 1