HomeMy WebLinkAbout19 Ann Road (17) DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR (1
BUILDING DEPARTMENT APPR
OVE 1540 SULLIVAN AVENUE
Bldg.Permit#
644-2511 ext. 230 NA
Inspector
Application must be printed or typed
Location of Job-
FEE SCHEDULE FT�enannt
$0-$1,000=$13.00 Street Lot No.Over$1,000=
$13.00 per$1,000
or any fraction thereof nation Apt.No.
APPLICANT
APPLICANT ADDRESS 11
APPLICANT PHONE#
10 W N S Fq OWNER 4_4
OWNER ADDRESS Iqr
0 E'' OWNER PHONE �Gq�U ss —f C�?09
C ESTIMATED COST$ o f S Q c- -D
�U IS THIS A CONTRACT COST? 13 Yes 0(No
FEE ENCLOSED$ �3 /
l��SOR CO�� TYPE OF JOB:
O New Installation
/irAlteration/Addition/Repair Revised 8/99
APPLICATION FOR PLUMBING 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 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
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. TYPE TATE
SIGNATURE OF APPLICANT DATE l C�