HomeMy WebLinkAbout115 Pine Tree Lane DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WINDSOR PERMIT#
Application is hereby:
BUILDING DEPARTMENT
APPR 1540 SULLIVAN AVENUE
Bldg.Permit#
644-2511 ext. 230
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to Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
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$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT 1
APPLICANT ADDRESS
APPLICANT PHONE#
OWN S F,q OWNER !
OWNER ADDRESS
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OWNER PHONE -
0
ESTIMATED COST$ f - cDa
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,� �► IS THIS A CONTRACT COST? Yes �✓1�To ]
FEE ENCLOSED$
TYPE OF JOB:
OR-Co New Installation
�4Alteration/Addition/Repair
Revised 410I H2002
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APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? ❑ YES ❑NO
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 2—
NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS�_ REMOTE DISCONNECT REQUIRED? ❑YES UNO
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
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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.
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C- -/o .33v
CONTRACTORS LICENSE N - TYPE STATE
DATE
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SIGNATURE OF APPLICAN Z �—