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APPLICATION FOR ELECTRICAL PERMITTOWNOFSOUTHWINDSORPERMIT#
y: BUII.,DING DEPARTMENT
1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
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$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS I .i'ti.1' ,
APPLICANT PHONE# 1-(0 U S ` ` L44
O W N S t ,
OWNER ,
OWNER ADDRESS 1(0,2
OWNER PHONE
ESTIMATED COST$ w
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$
TYPE OF JOB:
SOR-C0 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
RESIDENTIAL
BUILDING PERMIT APPLICATION?XYES NO
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
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.
L L
CONTRACTORS LICENSE NO. TYPE ST TE
SIGNATURE OF APPLICANT DATE w---