HomeMy WebLinkAbout103 Mill Pond Drive DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
TOWN OF SOUTH WIl�TDSOR PEYtMIT#
Application is hereby:
BUILDING DEPARTMENT
PROVED 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230 02 9 5-74?
Date q1BRuL1 2ing Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS ?Z�ZD-i u f'
(0C) 7
APPLICANT PHONE# U • Z 7 Z
0W N S OWNER
q� OWNER ADDRESS S �
i� OWNER PHONE
d o0
C ESTIMATED COST$
� IS THIS A CONTRACT COST? Yes No
f� FEE ENCLOSED$ l s,^�
r11r �� TYPE OF JOB:
�SOR Cps New Installation
�.Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR PLUMBING PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION?A YES ❑NO
;RESIDENTIAL
❑BUSINESS CURRENT USE AND OCCUPANCY
❑ASSEMBLY
❑MERCANTILE❑EDUCATIONAL FUTURE USE AND OCCUPANCY �4 7-1
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
❑ STORAGE
❑GARAGE ADDRESS
❑MIXED USE
CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION SIZE OF MAIN DRAIN
NO.OF TOILETS STYLE NO.URINALS STYLE
NO.OF BATHTUBS NO.OF SHOWERS NO.OF LAVATORIES
NO.OF CONDUCTORS SIZE NO.OF STACKS SIZE
AREA OF ROOF NO.OF CATCH BASINS NO.OF FLOOR DRAINS
NO.OF OTHER FIXTURES KIND
ARE TOILET COMPARTMENTS VENTILATED TO OUTER AIR BY A WINDOW ❑YES ❑NO
SIZE OF WINDOW IF NONE C.F.M.OF VENTILATOR
SIZE OF DUCTS SEWER OR SEPTIC TANK
SIZE OF WATER MAIN SIZE OF WATER PIPING&RISER
WATER HEATER: TYPE MANUFACTURER
DESCRIPTION OF WORK
C C C 9 d A 7`�l �c`�c� J—i X l-v 2 cc/J
T 2C0k*--7
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCR1BED AND 191-0
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LlUr l--)z NO. STATE
}
SIGNATURE OF APPLICANT - DATE �- f q-0