HomeMy WebLinkAbout170 Hillside DriveDEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WIl IDSOR
PERMIT#
Application is hereby:BUILDING DEPARTMENT
APPRO 1540 SULLIVAN AVENUE Bldg.Permit#
i
644-2511 ext. 230 o2 q Yo2 7
ate Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
170 N 1 LL.SJD2E DR,
0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS
APPLICANT PHONE# /.
W N S OWNER
O Fq OWNER ADDRESS oi7
OWNER PHONE0V.
0 ESTIMATED COST$ 'C O,
04
IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ 5 .
r1 TYPE OF JOB:
SOR C New Installation
Alteration/Addition/Repair
I
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? WYES NO
RESIDENTIAL
BUSINESS CURRENT USE AND OCCUPANCY S,ASSEMBLY
MERCANTILE
FUTURE USE AND OCCUPANCY IREDUCATIONAL
INSTITUTIONAL
FACTORY ENGINEER'S NAME PHONE
STORAGE
GARAGE ADDRESS
MIXED USE
CITY STATE ZIP
Other please specify)
TYPE OF INSTALLATION/WIRING METHOD f I LEA f 13
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 cS 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.
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT ' DATE o2y