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Home My WebLink About150 BROOK ST J � J APPLICATION FOR ELECTRICAL PERMIT DEPARTMENT DECISION TOWN OF SOUTH WINDSOR PERMIT# Application is hereby: BUILDING DEPARTMENT 1 ppn APP O 1540 SULLIVAN AVENUE ;,� Bldg.Permit# 644-2511 ext. 230 Date Building Inspector Application must be printed or typed FEE SCHEDULE Location of Job: $0-$1,000=$15.00 Oa K S� Over$1,000= Street No. Street Lot No. $15.00 per$1,000 or any fraction thereof Tenant Designation Apt.No. APPLICANT i e c ce G t'I Z L" APPLICANT ADDRESS 7 9S /)/e d era ec- ' y SoJ w �,r,�s,�'�- /C -�- 0(,3? S" APPLICANT'S PHONE 4j'3 OWNER r�\ J I OWN SF •( ,q� OWNER ADDRESS � OWNER PHONE ESTIMATED COST$ S U d L) IS THIS A CONTRACT COST? k- YeS No FEE ENCLOSED $ $ tea!0 O t$o TYPE OF JOB: *-,2Ilq SOR•CO�� New Installation IU Alteration/Addition/Repair Revised 03/05/10 • APPLICATION FOR ELECTRICAL PERMIT(Continued from reverse side) TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A BUILDING PERMIT APPLICATION? ❑ YES ❑ NO ❑ RESIDENTIAL CURRENT USE AND OCCUPANCY ❑ BUSINESS ❑ ASSEMBLY FUTURE USE AND OCCUPANCY ❑ EDUCATIONAL ❑ INSTITUTIONAL ENGINEER'S NAME PHONE ❑ FACTORY ❑ STORAGE ADDRESS ❑ GARAGE ❑ MIXED USE CITY STATE ZIP (Other please specify) TYPE OF INSTALLATION/WIRING METHOD SIZE OF SERVICE SIZE OF MAIN CONDUCTORS NUMBERS OF METERS NUMBERS OF DISCONNECTS AND RATINGS NUMBERS OF PANELS NUMBERS OF DISCONNECTS REQUIRED? ❑ YES ❑ NO NUMBERS 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 11 2 [LC t sQ� V tC c C0.b ar $� THE UNDERSIGNED HEARBY 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 PERFOR- MANCE OF SUCH WORK CONTRACTORS LICENSE N TYPE STATE SIGNATURE OF APPLICANT � / DATE l// C) BUILDING PERMIT./Lv.�.i STATE OF CONNEiMCUT WORKERS'COMPENSATION COMMISSION Building Permit Affidavit for Property Owners or Sole Proprietors (Conn.Gen.Stat. §31-286b) Property located at /S y 6 r-00 �-4- In the town of 'So, 1 ,oj tt c S�s Name of building permit applicant: Please check one: 1._I am the owner of the above property. 2. 'P I am the sole proprietor of a business. 2A.Name of business l-1 tt��t��C 1 P� Ai Z e 2B.Federal Employer Identification Number(FEI ) .............................................................................................................:...... Pursuant to§31-286b,"a property owner or sole proprietor[who]intends to act as a general contractor or principal employer"may provide either a certificate of workers'compensation insurance or a"swom notarized affidavit... stating that he will require proof of workers' compensation insurance for all those employed on the job site in accordance with this chapter." Please check one: 1._I do not intend to act as a general contractor or principal employer. [Sign and.stop here] Signature of applicant 2._I intend to act as a general contractor or principal employer.Applicant must either provide a certificate of workers'compensation insurance or sign the affidavit Wow. .................................................................................................................... Affidavit I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the"Workers'Compensation Act(Chapter 568). I understand that pursuant to§31-275 C.G.S.,officers of a corporation and partners in a Partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to pt cow Signature of applicant Subscribed and sworn to before me this day of ,200— (Notary Public!Commissioner of the Superior Court) 1000326 TOWN OF SOUTH WINDSOR, CT PERMIT NUMBER ELECTRICAL PERMIT DATE: 11/12/10 GIS ID: 14400150 FEE: 15.00 MUNIS APPLICATION# 201001508 BUILDING DESCRIPTION: APPLICANT LOCATION NAME: GIROUX ELECTRIC ADDRESS: 150 BROOK STREET ADDRESS: 495 NIEDERWERFER ROAD OWNER: GABOURY MILDRED B SOUTH WINDSOR,CT 06074 150 BROOK STREET SOUTH WINDSOR,CT 06074 DESCRIPTION OF WORK: REPLACING SERVICE CABLE AND METER. t SPECIAL CONDITIONS: ALL WORK TO BE DONE IN ACCORDANCE"WITH THE APPLICATION AND PLANS APPROVED BY THE BUILDING DEPARTMENT. CONSTRUCTION TYPE: OCCUPANCY GROUP: BUILDING OFFICIAL 11/12/2010 3:24 PM THE FEE ABOVE INCLUDES A$0.26 PER THOUSAND CT STATE EDUCATION SURCHARGE