ELECTRICAL SUBCODE
TECHNICAL SECTION
Date Received
Control #
Temp. Cut-in-Card Date Issued
Final Cut-in-Card Date Issued
Annual Pool Inspection
Date of Grounding and Bonding
Certification
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
Federal Emp. ID No.
FAX:
Contractor: Tel.
Address
e-mail
Exp. DateContractor License No.
Home Improvement Contractor Registration No. or Exemption Reason
Final
Service
Other
TCO
Constr. Serv.
Temp. Serv.
Rough
InitialApprovalFailureFailureType:
Dates (Month/Day)INSPECTIONS
Barrier-Free
Trench
Barrier-Free
Block Lot
Qualification Code
Work Site Location
zip codemunicipalitystreet
Address
e-mail
Tel.
Owner in Fee:
B. ELECTRICAL CHARACTERISTICS
Use Group Present Proposed
Pole/Pad Temporary Other[ ][ ][ ] #
Building Occupied as
Est. Cost of Elec. Work $
Utility Co.
JOB SUMMARY (Office Use Only)
Joint Plan Review Required:
Approved by:
Date:
CA
[ ]
CO
SUBCODE APPROVAL for CERTIFICATE
[ ] [ ]
CCO
SUBCODE APPROVAL for PERMIT
Date:
Approved by:
[ ] Bldg. [ ] Plumb. [ ] Fire. [ ] Elev.
PLAN REVIEW
Partial -Underslab Utilities Approved[ ]
Approved by:
Date:
No Plans Required
[ ]
Approved by:
Date:
Electric Plans Approved[ ]
Date Issued
Permit #
$
[ ] Licensed Elec. Contractor [ ] Certif'd Landscape Irrigation Cont'r [ ] Exempt Applicant
D. TECHNICAL SITE DATA
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of record and am authorized to make this
application and perform the work listed on this application.
DESCRIPTION OF WORK:
Applicant sign/Contractor
sign and seal here:
Print name here:
$
$
$
TOTAL FEE
Minimum Fee
Administrative Surcharge
State Permit Surcharge Fee
$
HP Garbage Disposal
HP/KW Space Heater/Air Handler
KW Central A/C Unit
KW Dishwasher
KW Elec. Dryer/Receptacle
KW Elec. Water Heater
KW Oven/Surface Unit
KW Elec. Range/Receptacle
Storable Pool/Spa/Hot Tub
Pool Permit/with UW Lights
TOTAL NUMBERS
Alarm Devices/F.A.C. Panel
Communications Points
Emergency & Exit Lights
Motors—Fract. HP
Light Poles
Detectors
Switches
Receptacles
Lighting Fixtures
KW Elec. Sign/Outline Light
AMP Motor Control Center
AMP Subpanels
AMP Service
KW Transformer/Generator
HP Motors 1/+ HP
KW Baseboard Heat
ITEMSSIZEQTY.
FEE (Office Use Only)
Applicant: When submitting this form to your Local Construction Code Enforcement Office, please provide one
original plus three photocopies.
U.C.C. F120 (rev. 11/09)
Internet version
