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ARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
pplication is hereby: q:zTOWNOFSOUTHWINDSOR
PERMIT#
BUILDING DEPARTMENT
jPROD 1540 SULLIVAN AVENUE Bldg.Permit#
G Z- j 644-2511 ext. 230 a c/F-3
Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE O
0-$1,000=$13.00 Street No. Street Lot No.
Over$1,000=
13.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT R' W
wwo B. enson
APPLICANT ADDRESS 409 New State Road
P.O. BOX 957
wAannho nwe ner6T0604o9r
APPLICANT PHONE#q2 w
OW N S F,q
OWNER
OWNER ADDRESS y
0 OWNER PHONE
C ESTIMATED COST$
1 U
low IS THIS A CONTRACT COST? )V!res 0 No
CJ FEE ENCLOSED$
TYPE OF JOB:
SDR CO
0 New Installation
el lteration/Addition/Repair Revised 8/99
APPLICATION FOR PLUMBING PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED A
BUILDING PERMIT APPLIC IONS S NO
SIDENTIAL
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
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 ' y SIZE OF WATER PIPING&RISER
WATER HEATER: TYPE - j %/ ' MANUFACTURER
DESCRIPTION OF WORK
JNJ
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 STATE
SIGNATURE OF APPLICANT DATE