HomeMy WebLinkAbout208 Old Farm Road (4)DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WIlVDSOR
PERMIT#
Application is hereby: l F/WFBUILDINGDEPARTMENT
APPROkildiiA
1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
Date Bspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
GCS
0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT IS o tt f c r t,${Z( S
APPLICANT ADDRESS D 14 S
1: f I r-x
APPLIC PHONE# !R(Q 0 - 9 7-5 30 L Z Cell g o V ``7 y y
OW N SF OWNER C-6 IVL K-i
q OWNER ADDRESS 3,0 9 (7 fal F IP m,5 kao
OD
O OWNER PHONE r2U 0 (o 4 -2 7S
C ESTIMATED COST$ j A 00. 0 0
a IS THIS A CONTRACT COST? Yes No
FEE ENCLOSED$ -
TYPE OF JOB:
New Installation
Alteration/Addition/Repair
I
I
i
Revised 4/01H2002 1
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APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? W YES NO
Of RESIDENTIAL
BUSINESS CURRENT USE AND OCCUPANCY
ASSEMBLY
MERCANTILE FUTURE USE AND OCCUPANCY R e—srEDUCATIONAL
INSTITUTIONAL
FACTORY ENGINEER'S NAME Al ot;:e--PHONE
STORAGE
GARAGE ADDRESS
MIXED USE
CITY STATE ZIP
Other please specify)
TYPE OF INSTALLATION/WIRING METHOD teM ,y
SIZE OF SERVICES 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 3
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
jif A A a f bas e r
0Aa 34, e,.5S aa s 6,v^ it r a
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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. YPE STATE
SIGNATURE OF APPLICANT DATE