HomeMy WebLinkAbout11 Kelly Road DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR Io.
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
Date Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE 1210
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof [Tenant Designation Apt.No.
APPLICANT �o!'I •�h� �� w � .���1�
APPLICANT ADDRESS .3 -S
glccow, �, d�GU� lC
APPLICANT PHONE#
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W S OWNER / T
i O s �q� OWNER ADDRESS lel
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�:* . ,� OWNER PHONE
ESTIlvIATED COST$ ( UG U
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ .,:;p
TYPE OF JOB:
.CO New Installation
4Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
�ItESIDENTIAL BUILDING PERMIT APPLICATION? ❑ YES ❑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/WIRING METHOD
SIZE OF SERVICE �W 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.
DESCR,ICPTION OF WORK
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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.
ONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT ` 1'l %2 DATE l0;VZ�
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