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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
Application is hereby:
TOWN OF SOUTH WINDSOR PERMIT#BUILDING DEPARTMENT � l�
APPROVED 1540 SULLIVAN AVENUE Bldg.Permit#
qf,j(0 1 644-2511 ext. 230
A Building Inspector
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Application must be printed or typed
FEE SCHEDULE Location of Job:
$0-$1,000=$13.00 Street No. Street Lot No.
Over$1,000
$13.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS /
C,�`, �,� _,.Vic, C27
APPLICANT PHONE# 932
O W N S OWNER
;q< OWNER ADDRESS / 2
SSS X
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OWNER PHONE G
A GL9 a
C MID ESTIMATED COST$
IS THIS A CONTRACT COST? ❑Yes 4er- `'€p
' G FEE ENCLOSED$ South Windsor
�SOR.CO11 TYPE OF JOB: BUILDING DEPARTMENT
❑ New Installation
e eP
A teration/Addition/R air Revised 5101
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 ENGINEER'S NAME PHONE
❑FACTORY
❑ STORAGE ADDRESS
❑GARAGE
❑MIXED USE CITY STATE ZIP
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 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.
CONTRACTORS LICENSE NO. TYP STATE
SIGNATURE OF APPLICANT DATE /�{%