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MENT DECISION APPLICATION FOR ELECTRICAL PERMIT
ation is hereby:
TOWN OF SOUTH WIl TDSOR
PERMIT#
BUILDING DEPARTMENT i:U Z
p 1540 SULLIVAN AVENUE Bldg.Permit#
JOE
644-2511 ext. 230
Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE
0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANTzz Zco c f o 0
APPLICANT ADDRESS
APPLICANT PHONE#Q
OWNER .
C OW N S Fq I5OWNERADDRF,S 00
OWNER PHONE t[ 3 s r'S u Aa?f
0
ESTIMATED COST$ p s
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ I S
TYPE OF JOB:
V New Installation
P"-'Alteration/Addition/Repair
Revised 4/01H2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? A YES NO
if RESIDENTIAL
BUSINESS
ASSEMBLY
CURRENT USE AND OCCUPANCY
MERCANTILE
L3 EDUCATIONAL FUTURE USE AND OCCUPANCY ram c
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-2 NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES _NUMBER OF OUTLETS
NUMBER OF LIGHT FIXTURES 1 NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
O G
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 c DATE