Fillable Medina County Building Department ELECTRICAL APPLICATION (Medina County)

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Medina County Building Department ELECTRICAL APPLICATION (Medina County)

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Main: 330-722-9220
E-mail to:
other_docs@medinaco.org
Fax: 330-764-8204
Medina County Building Department
Permit Center
791 W. Smith Rd.
Medina, Ohio 44256
h ttp:// medinaco.org/ building - department
ELECTRICAL APPLICATION
Project Address:
Building Permit #:
(if known)
City: Zip: Township:
Project Description:
Commercial Residential
Project Name: Utility Company:
New
Addition
Alteration/Repair
Alarm
Sign
Other
O.E.
Confirmation#
Owner’s Name:
Temp Pole:
Yes No
Address:
City: State: Zip:
Basement Area:
Ft
2
Phone:
Contractor Name:
Garage Area: Ft
2
Address:
First Floor Area: Ft
2
City: State: Zip:
Second Floor Area: Ft
2
Phone: Mobile:
Third Floor Area: Ft
2
**E-Mail is Required**
Other Area: Ft
2
E-Mail: Total: Ft
2
**
Make Check Payable To:
Medina County Treasurer
** We will email amount due after reviewing application
Comments:
Base Fee
Res. ($73) / Com. ($175)
:
$
SQFT x Rate
Res. ($.07) / Com. ($.08)
:
$
Temp Pole:
$
Subtotal:
$
State Fee
Res. (1%) / Com. (3%)
:
$
Tech Fee: $ 10.00
OCILB License#:
Expire Date:
Calculated Total:
$
By submitting this application, you are affirming that you are either the owner of record supplying a home
owner’s exemption affidavit OR a licensed contractor providing an OCILB# and have permission to act as agent
for owner of record.
Applicant’s Name: Date:
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Medina County Building Department ELECTRICAL APPLICATION (Medina County)

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Completed 25 January 2021

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