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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WINDSOR
PERMIT#
Application is hereby: BUILDING DEPARTMENT
1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
ate Building Inspector
Application must be printed or typed
FEE SCHEDULE
Location of Job:
S-a .,
0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT Y1
APPLICANT ADDRESS C3
SIIU (fr-- 1,AAe- EASi 6a4::6r-J46(3?'
APPLICANT PHONE#2
W N S OWNERN
Fq OWNER ADDRESS
4-1 C
OWNER PHONE
0
ESTIMATED COST$ 2) C
IS THIS A CONTRACT COST? Yes "No
FEE ENCLOSED$ L
TYPE OF JOB:
OR-C0 New Installation
L_,Ateration/Addition/Repair
Revised 4/01//20o2
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? YES NO
7 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/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
UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORKTHEUNDK DESCRIBED AND IS TO
C1 uCOMPLYWITHALLLOCALORDINANCESANDSTATEOFCONNECTICUTBUILDINGCODESINTHE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO. STATE
SIGNATURE OF APPLICANT DATE k 6 , \2—d Z