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DEPARTMENT DECISION APPLICATION FOR PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR Y 3
BUILDING DEPARTMENT
APPROVED 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
Date Building Inspector
EENMNMEEENNNEMMM�
Application must be printed or typed
FEE SCHEDULE Location of Job:
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000= �
$15.00 per$1,000
or any fraction thereof Te Designation Apt.No.
APPLICANT D
APPLICANT ADDRESS 113-D .57�
�2 _&V30
APPLICANT PHONE#
N OWNER
OW SF
q� OWNER ADDRESS
CO) OWNER PHONE
O
C ESTIMATED COST$ ®i
� IS THIS A CONTRACT COST? ✓Yes No
FEE ENCLOSED$ O_ d
TYPE OF JOB:
`FOR'C) ✓New Installation
Alteration/Addition/Rep air
Revised 4/01//2002
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APPLICATION FOR PftWfflffNG PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED H A
BUILDING PERMIT APPLICATION? S ❑NO
❑3ESIDDENTIAL
L BUSINESS
❑ASSEMBLY CURRENT USE AND OCCUPANCY
❑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
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
DESCRIPT ON OF WORK
THE UNDERSIUNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IRTC'
/ F
Y
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO. STATE
SIGNATURE OF APPLICANT DATE