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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR
_ BUILDING DEPARTMENT
PRO 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$1,000 Ax- � `?
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS
/t40,7 C-
APPLICANT PHONE#
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OWNER . xfi ,�'�L w
OWNER ADDRESS
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OWNER PHONE
ESTIMATED COST$ bc-->
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ `5
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TYPE OF JOB:
OR-Co New Installation
.X 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 ❑NO
❑RESIDENTIAL
USINESS CURRENT USE AND OCCUPANCY La
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0 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 CV 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.
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE A- a
36-ur1