HomeMy WebLinkAbout123 Hayes Road DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSORs-
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230 a ��
ate Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE
a3 a e5 ea
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS e / a
APPLICANT PHONE# 9 6
OWN S�'4 OWNER .
OWNER ADDRESS 1.2 -5
�..-��• � ��r,� sow 7� Gy���,�� C% o-�0 77�
0 OWNER PHONE 9 Y 9
C ESTIMATED COST$ 7tO O
� IS THIS A CONTRACT COST? Yes �No
FEE ENCLOSED$ /
TYPE OF JOB:
�SOR-C�� New Installation
�Alteration/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? ❑ YES ONO
❑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 h r
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 l
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.
V2 z�/ / ��
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE