Date Received

Control #
ELECTRICAL SUBCODE Date Issued
TECHNICAL SECTION Permit #
C. CERTIFICATION IN LIEU OF OATH
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
I hereby certify that I am the (agent of) owner of record and am authorized to make this
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
application and perform the work listed on this application.
Block Lot Qualification Code
Applicant sign/Contractor
Work Site Location sign and seal here:

Print name here:

Owner in Fee:
[ ] Licensed Elec. Contractor [ ] Certif'd Landscape Irrigation Cont'r [ ] Exempt Applicant
Tel. e-mail
D. TECHNICAL SITE DATA
Address DESCRIPTION OF WORK:
street municipality zip code

Contractor: Tel. 1234567890123456

1234567890123456
QTY. SIZE ITEMS
Address e-mail
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FEE (Office Use Only)
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Lighting Fixtures
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Receptacles 1234567890123456
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Contractor License No. Exp. Date Switches 1234567890123456
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Home Improvement Contractor Registration No. or Exemption Reason Detectors 1234567890123456
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Light Poles 1234567890123456
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Federal Emp. ID No. FAX:
Motors—Fract. HP 1234567890123456
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Emergency & Exit Lights
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B. ELECTRICAL CHARACTERISTICS
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Communications Points
Use Group Present Proposed 1234567890123456
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[ ] Pole/Pad # [ ] Temporary [ ] Other Alarm Devices/F.A.C. Panel 1234567890123456
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Building Occupied as Utility Co. 1234567890123456
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Est. Cost of Elec. Work $ 0 TOTAL NUMBERS 1234567890123456
$
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Pool Permit/with UW Lights 1234567890123456
JOB SUMMARY (Office Use Only)
12345678901234567890123456789012123456789012345678901234567890121234567890 Storable Pool/Spa/Hot Tub 1234567890123456
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PLAN REVIEW INSPECTIONS
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Dates (Month/Day) 1234567890123456
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KW Elec. Range/Receptacle 1234567890123456
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[ ] No Plans Required Type: Failure Failure Approval Initial 1234567890123456
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KW Oven/Surface Unit
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Rough
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[ ] Partial -Underslab Utilities Approved
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Barrier-Free
KW Elec. Water Heater 1234567890123456
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Date: Approved by:
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KW Elec. Dryer/Receptacle 1234567890123456
Trench
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12345678901234567890123456789012123456789012345678901234567890121234567890 KW Dishwasher 1234567890123456
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[ ] Electric Plans Approved Temp. Serv.
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HP Garbage Disposal 1234567890123456
Date: Approved by: Constr. Serv.
12345678901234567890123456789012123456789012345678901234567890121234567890 KW Central A/C Unit 1234567890123456
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TCO
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Joint Plan Review Required:
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Other
HP/KW Space Heater/Air Handler 1234567890123456
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[ ] Bldg. [ ] Plumb. [ ] Fire. [ ] Elev. 1234567890123456
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Service
KW Baseboard Heat
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SUBCODE APPROVAL for PERMIT Final HP Motors 1/+ HP 1234567890123456
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Date:
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Barrier-Free KW Transformer/Generator 1234567890123456
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Approved by: AMP Service 1234567890123456
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Temp. Cut-in-Card Date Issued
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SUBCODE APPROVAL for CERTIFICATE
Final Cut-in-Card Date Issued 1234567890123456
12345678901234567890123456789012123456789012345678901234567890121234567890 AMP Motor Control Center 1234567890123456
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[ ] CO [ ] CCO [ ] CA
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Annual Pool Inspection KW Elec. Sign/Outline Light
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Date:
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Approved by: Date of Grounding and Bonding
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Certification
Administrative Surcharge 1234567890123456
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$
Minimum Fee
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$
State Permit Surcharge Fee
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$
U.C.C. F120 (rev. 11/09) Applicant: When submitting this form to your Local Construction Code Enforcement Office, please provide one
original plus three photocopies.
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Internet version TOTAL FEE $