NOTE: All electrical work shall conform with Ordinance No. 366

I hereby certify that the statements contained herein
are true to the best of my knowledge and belief.

______________________________________
(Applicant's Signature)

-------------------------------------------------------FOR OFFICE USE ONLY -------------------------------------------------------

Zoning District ______ Permit # ________ Application Date ______Approved By _____

Fee Paid _______ Date Issued ______ Check # ______ Received by ______