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TYPE OR PRINT ONLY
COMPLETE RED BOXED AREAS
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BUILDING PERMIT
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Engineering Occupancy Fee
Affidavit TYPE OR PRINT ONLY Eng.Insp.Fee
TotalFee $IQ ,OO
To THE BUILDING DEPARTMENT,TOWN OF SOUTH WINDSOR,CT (Additional Cost)
The undeISIgned hereby applies to do work according to the following:
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Building
Appr.for CO
Applicant ZaJé R Lacu‘m”LocationofWork /20 Norfé ya w Drt LotNo.
Applicant‘s Address lL/S/WO"&Awueo K4 Teltt gootct’lo"!813
Town GIQ4-vnbvrv Zip cater/‘33 Lice (New;f0")
Owner KY 0th \l\vm‘\‘Architect
Owner's Address ‘20 Huf‘lkwtw bf Architect's Address
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Sq.Ft.New Area:1st FII 2nd Fli 3rd Fl.Tolal New Area
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