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VAN BUREN COUNTY                                                         Permit CBT-

APPLICATION FOR ELECTRICAL PERMIT                     Number

                                                                                                 Expires

Date of Application                                             Date Ready                                         or  Will Call

Type of Job (check one)

Residential:

             □New Single Family Dwelling (conventional construction)

             □New Manufactured Home (mobile, modular)

             □New Other                                                    □Remodel

Commercial 

            □New                                                                □Remodel

Industrial 

           □New                                                                 □Remodel

Property Owner

Job Address                                                                                                             Sec. No.

Property Number/Tax Plate Number

Property Owner Address

City                                                                                     State                                 Zip

Home Phone                                                                     Work Phone

Utility Company                            Energy Request No.                            Meter Number

Plan Review required?       □YES              □NO

Plan review requirement: Plans and Specifications must be submitted, before permit is issued, when the wiring or alteration to an electrical system is over 400 amps and is in excess of 3,500 S.F. in all buildings. They must be prepared by or under the direct supervision of an architect or engineer licensed pursuant to Act #299 of the Public Acts of 1980, as amended, and shall bear that architect’s or engineer’s signature and seal.

Have Plans Been Submitted?      □YES               □NO

Electrical Contractor Name

Address                                                                                            Phone

City                                                        State                                    Zip

Contractor License No.                                     Master License No.

Fed. ID or SS No.

Workers Disability Comp. Carrier                                 M.E.S.C. No.