All FIELDS ARE REQUIRED!  ENTER "N/A" IN FIELDS THAT ARE NOT APPLICABLE TO YOUR PERMIT! 

 DATE OF APPLICATION:*   

 WV CONTRACTOR ID:*      

 E-MAIL ADDRESS:*        
 
 LOCATION:*              
 
 OWNER:*                         

 KIND OF BUILDING:*          USED AS:*   

 TO BE COMPLETED ABOUT:*     

 CONTRACT AMOUNT:*       


SELECT ONE:

 NEW  ALTERATION  REPAIR  ADDITION

ITEM	NUMBER
CEILING OUTLETS
SWITCHES
PLUG RECEPTACLES
TOTAL OUTLETS
AIR HEATERS
RANGES
SIGNS
WATER HEATER
LIGHTING CIRC.
OTHER CIRC.
TOTAL CIRCUITS
MOTORS
PANEL SIZE
RANGE COND.
SUB FEEDER SIZE

 CONTRACTOR NAME & ADDRESS:       


 CITY:      STATE:      ZIP CODE: 




                       or 


 PLEASE CALL OUR OFFICE 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.


                                         
 


                                                                      Electronic Form design by Don Wade 2006