Fillable CITY OF DANBURY ANNUAL APPLICATION FOR REGISTRATION OF (City of Danbury)

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CITY OF DANBURY ANNUAL APPLICATION FOR REGISTRATION OF (City of Danbury)

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CITY OF DANBURY
CONSUMER PROTECTION
Weights and Measures
(203) 796-8094
ANNUAL APPLICATION FOR REGISTRATION OF WEIGHING AND MEASURING DEVICES
* All spaces must be completed - please print or type.
* Application fees are non-refundable.
* Multiple locations need to file separate applications and payments for each location.
* This application must be accompanied by a check or money order (NO CASH) for the appropriate amount, made
payable to: City of Danbury Consumer Protection
Mail To: City of Danbury - Consumer Protection
Attn: Finance Dept.
155 Deer Hill Avenue
Danbury, CT 06810
Business Trade Name:
Federal lD or Soc. Sec No.
Business Street Address (Location of Business)
City
State
Zip Code
Business Telephone Number
Corporation Name (If Applicable) Billing Address
Applicant's Name
Applicant's Title
DEVICE
TYPE
FEE PER
UNIT
NO.
UNITS
TOTAL
AMOUNT
DEVICE
TYPE
FEE PER
UNIT
NO.
UNITS
TOTAL
AMOUNT
Scale 0 TO 50 Ibs.
In capacity
$ 35.00
Truck Petroleum Meter $ 70.00
Scale OVER 50 Ibs.
In capacity
$140.00
Taxi Meter $ 35.00
Retail Petroleum
Dispenser Meter
$ 35.00
TOTAL AMOUNT DUE
I certify that I am authorized to exercise principal authority in the State of Connecticut on behalf of the above applicant for the
registration of these weighing and measuring devices. I also subscribe and affirm under the penalties of perjury, that the statements
made in this application have been examined by me and to the best of my knowledge and belief are true and correct.
Signature of Applicant:_________________________________________________________ Date: ____________________
***FOR OFFICE USE ONLY***
Notes:
Approval Date:
Registration Expires:
New Registration #
Inspection Dates:
Inspected By:
Fee Due:
Balance Due:
Current Registration #
New
License
Addition
of Devices
Name
Change
Renewal
Application
Date Collected:
Fee Collected
Check or MO #
(Rev 07/12)
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CITY OF DANBURY ANNUAL APPLICATION FOR REGISTRATION OF (City of Danbury)

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Completed 18 January 2021

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