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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR /G Q
BUILDING DEPARTMENT
APPR 1540 SULLIVAN AVENUE
Bldg.Permit#
ve _ 644-2511 ext. 230 7 g
ate Building Inspector
Application must be printed or typed
Location o ob:
FEE SCHEDULE F�Te-nant
Mnyj
z•$0-$1,000=$13.00 Street Lot No.
Over$1,000=
S 13.00 per$1,000
or any fraction thereof ation Apt.No.
/
APPLICANT /
APPLICANT ADDRESS /
APPLICANT PHONE# '/ D ®" Z� 1o�
SOW N SFq OWNER /` �/ C b / NTZ-
OWNER ADDRESS [ /CO P}
a 1 , �f Sc�(At-t Lc,rhl .SC.) C� .
,w 1ti
QV' OWNER PHONE ��//��
C ESTIMATED COST$ ! W, 00
IS THIS A CONTRACT COST? M Yes O No
f S 2
lGr' �CJ FEE ENCLOSED$
OR-
CO�� TYPE OF JOB:
0 New Installation
f-Alteration/Addition/Repair Revised 8/99
I
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATEDEESS O A
J / BUILDING PERMIT APPLICATION? W Wl NO
❑'RESIDENTIAL
❑BUSINESS CURRENT USE AND OCCUPANCY
❑ASSEMBLY
❑MERCANTILE FEE USE AND OCCUPANCY
❑EDUCATIONAL
❑INSTTTUTIONAL ENGINEER'S NAME PHONE
❑FACTORY
❑ STORAGE ADDRESS
❑GARAGE
❑MIXED USE CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION/WIRING METHOD f61/;2 `
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/
/l/
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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CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE