HomeMy WebLinkAbout1075 Pleasant Valley Road (4)DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT PERMIT#
Application is hereby:TOWN OF SOUTH WIlNDSOR
BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230 d
DatJ Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
Ll 7
0-$1,000=$15.00 Street No. Street Lot No.
Over$19000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS
7-.-Z"
APPLICANT PHONE# 8GG-8'ji- f fr
OW N $• OWNER i ar to .r
q OWNER ADDRESS O 7
h
411
OWNER PHONE 8 2f- Z Y
0
C ESTIMATED COST$ /5DO
U
IS THIS A CONTRACT COST? Yes ,-"'-No
CJ FEE ENCLOSED$ 3 y-
TYPE OF JOB:
OR-Co New Installation
Alteration/Addition/Repair
Revised 4/01//2002
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 OCCUPANCYEDUCATIONAL
INSTITUTIONAL
FACTORY ENGINEER'S NAME PHONE
STORAGE
GARAGE ADDRESS
MIXED USE
CITY STATE ZIP
Other please specify)
TYPE OF INSTALLATION/W UNG METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS /
d//c7
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.
932 y;7 T
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICAN DATE