HomeMy WebLinkAbout1075 Pleasant Valley Road (4) DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby:
TOWN OF SOUTH WIlNDSOR
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE
Bldg.Permit#
644-2511 ext. 230 � d
'DatJ Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
�Ll 7�
$0-$1,000=$15.00 Street No. Street Lot No.
Over$19000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS
7-.-Z"
APPLICANT PHONE# 8GG-8'ji- f�fr
O
W N $�• OWNER i�ar�to .�r
q� OWNER ADDRESS /O 7
h
411
.# OWNER PHONE 8 2f- Z Y�
0
C ESTIMATED COST$ /5DO
* U IS THIS A CONTRACT COST? Yes ,-"'-No
CJ
FEE ENCLOSED$ 3 y- �
TYPE OF JOB:
OR-Co New Installation
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? ❑ 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/W UNG METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS /d//c7
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.
�/--/932 y;7 T
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICAN �- DATE