HomeMy WebLinkAbout155 Niederwerfer Road DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
TOWN OF SOUTH WIl�TDSOR PERMIT# c.
Application is hereby: ���(p
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE Bldg.Permit#
v Jam- 644-2511 ext. 230
15atel Building Inspector
Application must be printed or typed
FEE SCHEDULE 1 -�� Neiclerwtr Location of Job:
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$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT mt&atl Sat '
APPLICANT ADDRESS 151W
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APPLICANT PHONE.
O W N S t OWNER19,or
q� OWNER ADDRESS .165 NUCIP-11 r
OWNER PHONE "l
C ESTIMATED COST$_
IS THIS A CONTRACT COS ? Yes No
FEE ENCLOSED$
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TYPE OF JOB:
�R C 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
C
C�'RESIDENTIAL �BUILDING PERMIT APPLICATION? 0' S ❑NO
❑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 �gq - 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 zq-5 MANUFACTURER
DESCRIPTION OF WORK
✓►'�'C�-
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT V5 PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
3700 T7 D r C�
CONTRACTORS LICENSE N JA TYPE STATE
SIGNATURE OF ArrLICANT
DATE �I D