HomeMy WebLinkAbout137 Old Farm Road DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
TOWN OF SOUTH WIIVDSOR PERMIT#
Application is hereby: ` oZc.2c>�
BUILDING DEPARTMENT
APPROVED 1540 SULLIVAN AVENUE Bldg.Permit#
(r7jo� ��_ 644-2511 ext. 230
ate Building Inspector
Application must be printed or typed
FEE SCHEDULE Locati of Job:
4 Lxm S S,wl A/D JA
$0-$1,000=$15.00 Street o. Street Lot No.
Over$1,000=
$15.00 per$1,000A pev
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS 14L
APPLICANT PHONE#
W N S OWNER
St. OWNER
OWNER ADDRESS
C OWNER PHONE
C ESTIMATED COST$ 15v
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ /-:5- cc)
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TYPE OF JOB:
OR-Co New Installation
f/Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR PLUMBING PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITYNO
El PERMIT APPLICATION? YES
❑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 SIZE OF MAIN DRAIN
NO.OF TOILETS STYLE NO.URINALS STYLE
NO.OF BATHTUBS NO.OF SHOWERS NO.OF LAVATORIES
NO.OF CONDUCTORS SIZE NO.OF STACKS SIZE
AREA OF ROOF NO.OF CATCH BASINS NO.OF FLOOR DRAINS
NO.OF OTHER FIXTURES KIND /'CJ L.L/I
ARE TOILET COMPARTMENTS VENTILATED TO OUTER AIR BY A WINDOW ❑YES ❑NO
SIZE OF WINDOW IF NONE C.F.M.OF VENTILATOR
SIZE OF DUCTS SEWER OR SEPTIC TANK
SIZE OF WATER MAIN SIZE OF WATER PIPING&RISER
WATER HEATER: TYPE MANUFACTURER
DESCRIPTION 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.
PF ) 2&:x)!�S S -3
CONTRACTORS LICENSE NO. STATE
SIGNATURE OF APPLICANT DATE 1 :2