HomeMy WebLinkAbout125 Ellington Road (9) DEPARTMENT DECISION APPLICATION FOR SPRINKLER PERMIT
TOWN OF SOUTH WIl�TDSOR PERMIT#
Application is hereby: j al�
BUILDING DEPARTMENT
APPR 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
Date Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
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$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT r4TQ4 6 7— ON �L
APPLICANT ADDRESS Oil) co/e/°O) f4/9-
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APPLICANT PHONE#
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N S OWNER C of /moo r
°l. �q< OWNER ADDRESS 1 as-
+Ir # OWNER PHONE
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C ESTIMATED COST$ 1 k—a
* IS THIS A CONTRACT COST? 4---Yes No
FEE ENCLOSED$
TYPE OF JOB:
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OR-C New Installation
Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR SPRINKLER PERMIT (Continued from reverse side)
TYPE OF BUILDING TYPE OF CONSTRUCTION USE GROUP NO. OF STORIES
❑RESIDENTIAL
❑BUSINESS IS THIS APPLICATION ASSOCIATED WITH A
❑ASSEMBLY BUILDING PERMIT APPLICATION? ❑ YES ❑NO
❑MERCANTILE
❑EDUCATIONAL CURRENT USE AND OCCUPANCY
❑INSTITUTIONAL
❑FACTORY FUTURE USE AND OCCUPANCY
O STORAGE
❑GARAGE ENGINEER'S NAME PHONE
❑MIXED USE
(Other please specify) ADDRESS
CITY STATE ZIP
KIND OF INSTALLATION
SIZE OF MAIN DRAIN WATER PRESSURE AT STREET(PSI)
ARE SPRINKLER HEADS ALTERED? ❑YES ❑NO
IF YES,CHECK ALL THAT APPLY: 0ADDED ❑DELETED ❑ALTERED
IF MORE 3 HEADS ARE ADDED HYDRAULIC CALCULATIONS ARE PROVIDED BY(CHECK ONE)
MORE
OFESSIONAL ENGINEER ❑INSURANCE COMPANY
WATER FLOW WATER PRESSURE AT SPRINKLER HEADS(PSI)
ARE PUMPS REQUIRED? C YES ❑NO IF YES,CHECK ALL THAT APPLY:
W FIRE ❑BOOSTER ❑OTHER
ARE STANDPIPES PROVIDED? ❑YES ❑NO IS A SPRINKLER SYSTEM PROVIDED? ❑YES ❑NO
SPRINKLER SYSTEM MAIN WATER SUPPLY RATING GPM
TOTAL DYNAMIC HEAD(TDH)OF FIRE PUMP PSI
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.
F-1 F( C-7-'
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE