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RTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WINDSOR PERMIT#
plication is hereby: /W d g
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE
Bldg.Permit#
45f �a 644-2511 ext. 230 q s-3
Building Inspector
Application must be printed or typed
FEE SCHEDULE LOCI* of Job:
To,LOW 60 )
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
14
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT ,
APPLICANT ADDRESS l 8 Sy,w R,f e l 14,✓
Z!5- �1rZ Tol�2 D c 7— 0611,6
APPLICANT PHONE#
W N S OWNER "Z 0 rto
�44( OWNER ADDRESS L
AQ
OWNER PHONE 20 r J-
UESTIMATED COST$pal n o
�� IS THIS A CONTRACT COS _ZYes No
FEE ENCLOSED$
TYPE OF JOB:
OR-C0 !,/ New Installation
Alteration/Addition/Repair
Revised 4/01H2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? ❑YES N 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
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.
rrs 9 7� r
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE
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