Date:                            Contractor       Homeowner

Homeowner's Name:

Address:  Township: 

Postal Code:

Cross Street 1: 

Cross Street 2:

Homeowner's Tel: Cell:

 Email:

Store Name:  Township:

Village:

Permit #: Section #:  Block #: 

Lot #:

Contractor's Company: 

License #:

Address:  Township: 

Postal Code: 

Contractors Tel:  Email:

TYPE OF WORK PERFORMED

New Residential   New Commercial   Addition   Renovation  

Detached Garage   

Basement  First Floor  Second Floor Attic  Indoor  Outdoor  Survey

Pool  Hot Tub  Service Only  Shed/Other Structure

SERVICE

Services Only  New Installation  Service Upgrade 

Service Size: amps    Phases:

Relocate POA   Overhead   Underground  Fax Temp  

Number of Meters:

INSTALLATION

Switches  Receptacles  Light Fixtures  GFI   Smoke Detectors  

CO Detector

Dryer   Washer   Fans   Dishwasher   Range   Oven   Heaters

ITEM COUNT

Switches:  Light Fixtures: Receptacles:  

GFI:

Fans:   Smokes:   Carbons:

In addition to our application the Town of Smithtown requires an additional permit.
Download Smithtown Permit