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DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT PERMIT#
TOWN OF SOUTH WINDSOR
Application is hereby: BUILDING DEPARTMENT
AppR 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext.'230
3 S/—
at Building Inspector j
Application must be printed or typed
Location ofJob:
FEE SCHEDULE
0-$1,000=$15.00 Street No.Street Lot No.
Over$1,000=
15.00 per$1,000 Apt.No.
or any fraction thereof Tenant Designation
APPLICANT L.I1,,C C r`(-
III
APPLICANT ADDRESS,
APPLICANT PHONE#
ow N s
OWNER .
9' c,c r -4< OWNER ADDRESS
s VV4 A/
OWNER PHONE
ESTIMATED COST$
IS THIS A CONTRACT COST? es No
FEE ENCLOSED$ S
TYPE OF JOB:
SQjt.C N?
teration/Adddition/Repair
on
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED
SIDENTIAL
BUILDING PERMIT APPLICATION? S NO
BUSINESS CURRENT USE AND OCCUPANCY SASSEMBLY
MERCANTILE
El EDUCATIONAL FUTURE USE AND OCCUPANCY
INSTITUTIONAL
FACTORY ENGINEER'S NAME PHONE
STORAGE
GARAGE ADDRESS
MIXED USE
Other please specify)
CITY STATE ZIP
TYPE OF INSTALLATION/WIRING METHOD l
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
C Cy
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 `— `