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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR
BUILDING DEPARTMENT
APPROVED 1540 SULLIVAN AVENUE Bldg.Permit#
9/
36 tlZ S�� 644-2511 ext. 230
Date Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
I Li e I 1y1 pyky&
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT LA4j Ll
APPLICANT ADDRESS tS
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APPLICANT PHONE# k D + {p y d 9
N S OWNER . e�t'_lt�l d%-,
�q< OWNER ADDRESS mcf s r
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OWNER PHONE -c f3 0 -IR�l C-)L
ESTIMATED COST$ ASW, t:)O
IS THIS A CONTRACT COST? Yes jL No
FEE ENCLOSED$ S
TYPE OF JOB:
New Installation
V 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?AYES ❑NO
®RESIDENTIAL
❑BUSINESS CURRENT USE AND OCCUPANCY (� `� Q ����✓
❑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
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.
6- C-,- -
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE 9 8