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2. 

4. THE PERMIT ISSUED ON THIS APPLICATION WILL AUTHORIZE ONLY WORK SPEDIFIED CONTRACTOR MUST GIVE COMPLETE INFORMATION AS INDICATED BELOW.

6. Name of Owner or User *
8. Number and street of installation *

   (STREET CORNER LOCATIONS NOT ACCEPTABLE)

10. Property Index number
11. Phone Number of Owner or User*
13. Person, Firm or Corporation Doing Work*
14. Phone Number*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Qualified Electrician
23. Registered At
24. No.
26. Value of Installation*
27. Scope of Work*
29. Check class of work applied for *

    1. WIRING
    2. REVISIONS

    1. SIGN
    2. MAINTENANCE

33.                                                                                                         SIGNS

35. QUANTITY
36. OUTSIDE
37. INSIDE
38. SIZE IN SQUARE FEET
40. AMPERAGE
41. VOLTAGE
42. PHASE
43. WIRE
45. AMPERAGE
46. VOLTAGE
47. PHASE
48. WIRE
50. AMPERAGE
51. VOLTAGE
52. PHASE
53. WIRE

57.                                                                        LIGHTING CIRCUITS AND OUTLETS 

59. 2 WIRE CIRCUTITS
60. NUMBER
62. 3 WIRE CIRCUTITS
63. NUMBER
65. 4 WIRE CIRCUTITS
66. NUMBER
70. LAMP, FIXTURES, SOCKETS, RECEPTACLES
72. POWER DEVICES (LIST SEPARATELY)

    NO. OF: Power Consuming Devices such as Air Conditioners, Motors, Ranges, etc.

74. DEVICES
75. OUTPUT/LOAD
77. DEVICES
78. OUTPUT/LOAD
80. DEVICES
81. OUTPUT/LOAD
83. DEVICES
84. OUTPUT/LOAD
86. DEVICES
87. OUTPUT/LOAD
89. DEVICES
90. OUTPUT/LOAD
92. DEVICES
93. OUTPUT/LOAD
95. DEVICES
96. OUTPUT/LOAD
98. TOTAL NO. OF MOTORS

100.                                                   Work must start within 90 days of permit, or permit is null and void. 

Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field