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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WINDSOR PERMIT#
Application is hereby: �
BUILDING DEPARTMENT
1540 SULLIVAN AVENUE Bldg.Permit#
/ 644-2511 ext. 230
ate Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
\-S- a .,
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT Y1
APPLICANT ADDRESS C3
SIIU (fr-- 1,AAe- EASi 6a4::6r-J46(3?'
APPLICANT PHONE# 2
W
N S OWNERN
Fq� OWNER ADDRESS �
4-1
C
OWNER PHONE
0
ESTIMATED COST$ 2) C
IS THIS A CONTRACT COST? Yes "No
FEE ENCLOSED$ ��L
TYPE OF JOB:
OR-C0� New Installation
_L_,Ateration/Addition/Repair
Revised 4/01//20o2
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
�� BUILDING PERMIT APPLICATION? ❑ YES ❑NO
�7 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
UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK THE UND K DESCRIBED AND IS TO
C1�u�►
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO. STATE
SIGNATURE OF APPLICANT DATE k 6 , \2—d Z