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Location (Street # & Street Name):_________________________________________________

Owner: _________________________________________ Address: _____________________

City: ______________________State: ___ Zip: _______________ Telephone:

__________________

Contractor: ______________________________________ Address: ______________________

City: ______________________State: ___Zip: _______________ Telephone: _______________

N.H. Master Electrician License Number: _________________ Estimated Cost

_________________

Residential Property Commercial Property

Yes No (Is this work for a NEW LIVING UNIT?)

Device Fee Each No New

Meters

Fee

Each

No Devices Fee

Each

No Fixtures Fee

Each

No

100 amp $ 5.00 Domestic $ 4.00 Outlets $ .50 Smoke Det. $ 2.00

200-400 $ 7.00 Quick Rec. $ 4.00 Light Fix. $ .50 Flouresc. $ 1.00

400-600 $ 9.00 Off Peak $ 4.00 Switches $ .50 Neon $1 /4

600-800 $ 12.00 Primary $ 4.00 GFIC $ 1.00 Hi-Intens $ 10.00

800-1K $ 15.00 Power $ 4.00 1000 w/+ $ 10.00

1K plus $ 18.00 Other

City of Somersworth

Development Services Dept.

1 Government Way

Somersworth NH 03878

(603) 692-9522 Fax: 692-9575

Map # _____ Lot # ____

Zoning: _____________

7/28/04

Application For

Electrical

Permit

Special

Outlets

Fee

Each

No Equipment Fee

Each

No Equipment Fee

Each

No Description Of Work

1-9 KW $ 5.00 Range $ 4.00 Oil Burner $ 3.00

10-24 KW $ 8.00 Oven $ 4.00 Kitchen Fan $ 3.00

25 plus KW $12.00 Washer $ 4.00 Bath Fan $ 3.00

Dryer $ 5.00 Elect. Ht 10KW $ 5.00

Air Cond. $ 4.00 Compressor $ 5.00

Hair Dryer $ 5.00 Microwave $ 3.00

*** When Applicable

Plans must be submitted to

Somersworth Fire Dept for

Approval

Disposal $ 3.00 Paddle Fan $ 3.00

Motors $ 3.00 Motors hp + $ 5.00

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*************************(DO NOT WRITE IN THIS

SPACE)*************************

Approved By

Code Officer: ____________________________________________________________ Date: ________________________

Department of Development Services

Code Enforcement Office

Instructions for Permit Applications

1. All information must be printed legibly.

2. Owner name, address and phone number.

3. Location and address of work site.

4. Complete description of work to be done.

5. Number of fixtures, appliances and equipment to be installed.

6. Plans must be submitted on all new buildings and major renovations.

Notes:

The property owner of record may execute their right to perform their own electrical/plumbing work on their residence

if he or she lives at the residence for a period of not less than one (1) year from the date of final approval of this workand the residence is a Single Family Dwelling occupied by the owner of record.

It is the responsibility of all contractors, electricians and plumbers to obtain the necessary permits from the Code

Enforcement office at City Hall before ANY work has begun. Work must begin within six (6) months of the issuance

of any permit.

Electricians and plumbers contractors must have a valid license from the State of New Hampshire to obtain a permit.

Permits are not transferable.

It is the responsibility of the contractor to obtain all inspections required. A rough-in inspection is required before

any work is covered, and a final inspection is required when all work is complete. A forty-eight (48) hour notice is

required for any inspection. This signed application constitutes consent on the applicants part to allow for all

inspections at the property location listed.

No permit will be issued until all of the above information is furnished, and all the above conditions met.

It is the responsibility of the property owner and/or the contractor to contact PSNH after the City approval sticker

has been applied to arrange for hook-up.

INSPECTIONS REQUIRED: (48 hours notice required)

1. When rough-in is complete and visible (Rough)

2. When job is complete, but before occupancy (Final).

Total Permit Fees:

Services

Meters

Devices

Fixtures

Special Outlets

EquipmentTOTAL

Minimum Fee is 10

dollars

If total is less than 10

PAID BY: _________________________ DATE:____________________

RECD BY: __________________ CASH CHECK # _____________

REVERSE SIGNED:

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Code Enforcement Approval would certify that the applicant could proceed with installing Electrical fixtures in

accordance with specifications submitted. Any deviation from the specifications submitted will require an amendment

to this permit or additional permits.

If you have any questions, feel free to contact the Code Enforcement office at 692-6522 or 692-9520.

Statement of Compliance:I have read and understand the statement and hereby agree to all of the terms stated therein. I agree to abide by any

and all codes relating to my field of work, including all national, state and local codes. I also realize that any false

statement made in the application for permit may be grounds for revocation of said permit.

_____________________________________ _____________________________________

Applicant Signature Date