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Revised 4/01//2002
DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
Application is hereby:
TOWN OF SOUTH WINDSOR ZA
MIT#
BUILDING DEPARTMENT
APPROV D 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230
Date g nspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
$0-$1,000=$15.00 Street No. Street Lot No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS 3 tc±"
�vL4� JSc✓ Cyr 0��(
APPLICANT PHONE# `Z (J ? o
OWNERQ�
11%
OWN S lr /
q< OWNER ADDRESS
Oa , OWNER PHONE
C ESTIMATED COST$ )2av
A%W IS THIS A CONTRACT COST _Yes _
ojt.+�� FEE ENCLOSED$
rj
TYPE OF JOB: tD1 sO .CO �
R _New Installation
Alteration/Addition/Repair
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? ❑ YES ❑NO
,8�RESIDENTIAL
BUSINESS CURRENT USE AND OCCUPANCY
❑ASSEMBLY
❑MERCANTILE FUTURE USE AND OCCUPANCY
❑EDUCATIONAL
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
❑STORAGE
❑GARAGE ADDRESS
❑MIXED USE
CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATIONIWIRING METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS
NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS REMOTE DISCONNECT REQUIRED? O 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
LJ
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Gr.rJ V k®-'
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.
JZ-Z661
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CONTRACTORS LICENSE TYPE STATE
)
SIGNATURE OF APPLICANT DATE G 16-2