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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
PERMIT#
Application is hereby: TOWN OF SOUTH WINDSOR tBUILDINGDEPARTMENT S
PRQ 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
v3. j
ate Building Inspector
Application must be printed or typed
FEE SCHEDULE Loca'on of Job:
4 4 S. -0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLIC ADDRE
APPLICANT PHONE#
oW N S F OWNER , ka-Lr 1
q OWNER ADDRESS
OWNER PHONE 4O ' 77 a
C ESTIMATED COST$ S r
W IS THIS A CONTRACT COST? Yes No
r
FEE ENCLOSED$
TYPE OF JOB:l SOR.Cp New Installation
lteration/Addition/Repair
i
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
SIDENTIAL
BUILDING PERMIT APPLICATION? YES I NO
BUSINESS CURRENT USE AND OCCUPANCY
ASSEMBLY
MERCANTILE FUTURE USE AND OCCUPANCY e,
EDUCATIONAL
INSTITUTIONAL
FACTORY ENGINEER'S NAME PHONE
STORAGE
GARAGE ADDRESS
MIXED USE
CITY STATE ZIP
Other please specify)9
TYPE OF INSTALLATION/WIRING METHOD
SIZE OF SERVICE /0 O SIZE OF MAIN CONDUCTORS -?04—oZ
NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS /REMOTE DISCONNECT REQUIRED? YES KNO
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
SO C c-
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.
Ct
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE v//,Z v 7