Application for Electrical Permit
Applicant’s signature Print name Date
Section 2 – Description of Property and Project
Contractor is required to schedule a rough-in inspection before any concealment.
By signing the application, the applicant certifies that the installation will comply with the regulations of the Newburgh Heights
Building Code and State Codes.
TO THE BUILDING COMMISSIONER: This application is submitted for a permit to erect, add to, alter or repair a structure as described
in this application and any drawings which accompany it. The acceptance of the permit shall be considered an agreement on the part of the
applicant or his agents to comply with the Building and Zoning codes of the City of Newburgh Heights, or other orders, requirements or
specifications slated in the permit.
In signing this application, the contractor or owner’s agent certifies that the work is authorized by the owner or record.
Applicant is Owner Contractor Owner’s agent
Permit No. Date Received
Type of Structure
Single family
Two family
Three family
Apartment
Commercial
Other (describe)
Type of Work
New structure
Addition
Alteration
Repair
Replacement
Other (describe)
Type of installation
Light fixture
Receptacle outlet
High intensity lights
Panel - MAIN
Panel - SUB
Service upgrade
Service replacement
Meter base
Exhaust fan
Baseboard heater
Range
Air conditioner
Type of installation
Emergency light
Motors
Generator
Signs
Electric furnace
Temporary lighting
Hot-tub/Spa
Water heater
Smoke detectors
Other
# of units# of units
Village of Newburgh Heights Housing and Building Department
3801 Harvard Ave., Newburgh Heights OH 44105 Phone: 216-641-4654
Estimated cost of Project $
Date
Section 1 – General Information
PLEASE PRINT OR TYPE
Address of construction ____________________________________________________________________________
Owner’s name ___________________________________________________ Phone ___________________________
Owner’s address __________________________________________________________________________________
Contractor ______________________________________________ Business phone ___________________________
E-mail address ________________________________________________________
Contractor’s address _______________________________________________________________________________
Street City State Zip
