Site Address_________________________________________________________________________________

Business or Project Name_______________________________________________________________________

Last or Corporate Name_________________________________________________ First__________________

Mailing Address______________________________________________________________________________ City________________ State____ Zip___________ Phone________________ Cell________________

Contractors Name__________________________________________________ Phone________________

Master Electricians Name____________________________________________ CE________________

Power Company_____________ Health Dept. Release _______________ ME________________

Single Family___ Two Family___ Townhouse___ Condominium___ Modular___

Multi-Family___ Basement___ Detached Accessory___ Garage Addition___ Room Addition___ Farm Bldg___ Swim Pool___ HVAC___ Sign___ Service change___ Partial Rewire___ Complete Rewire___ Communication Booster___

Temporary___ Pole Service___ RR Signal___ Commercial___

Other _______________________________________________________________________________________

Cost Of Commercial Electrical Work_______________________________________

I hereby certify that I am the owner of record of the named property, or that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized agent and I agree to conform to all applicable laws of this jurisdiction. In addition, if a permit for work described in this application is issued, I certify that the code official or the code official’s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. I further testify that the above information is true and accurate.

Departmental Approvals: Zoning____________________________ Date________________­­_