HomeMy WebLinkAbout15 Marty Lane [4bate
MENT DECISION APPLICATION FOR ELECTRICAL PERMIT
ation is hereby:
TOWN OF SOUTH WIl�TDSOR PERMIT#
BUILDING DEPARTMENT i:U�Z
p 1540 SULLIVAN AVENUE Bldg.Permit#
JOE 644-2511 ext. 230
Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANTzz��Zco c f o 0
APPLICANT ADDRESS ,
APPLICANT PHONE# Q
OWNER .
'C OW N S Fq < < (I5
OWNER ADDRF,S 00�
OWNER PHONE t[ 3 s�r'�S u Aa?f
0
ESTIMATED COST$ p� s
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ I S
TYPE OF JOB:
V New Installation
P"-'Alteration/Addition/Repair
Revised 4/01H2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? A YES ❑NO
if RESIDENTIAL
❑BUSINESS `
❑ASSEMBLY CURRENT USE AND OCCUPANCY
❑MERCANTILE
L3 EDUCATIONAL FUTURE USE AND OCCUPANCY {ram c
❑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-2 NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES _ NUMBER OF OUTLETS _
NUMBER OF LIGHT FIXTURES 1�NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
O G
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 ''c� DATE �