Housing Electrical Permit Application Form
Planning, Property and Development Department
ER
Unit 31 • 30 Fort Street • Winnipeg Manitoba R3C 4X7
This is NOT a permit
Street No.
LOCATION OF
WORK
Street Name
Unit/Suite/#
HOMEOWNER APPLICANT
Date
ELECTRICAL CONTRACTOR APPLICANT
(HOMEOWNER APPLICANTS MUST APPLY IN PERSON)
Homeowner Name (print)
Contractor Name (print)
Licence No.
Company Name
Daytime Phone No.
Signature
Email Address
NAME OF BUILDER (if applicable)
TYPE OF
ELECTRICAL
WORK
PROPOSED
RELATED BLDG. PERMIT NO.
New Construction / Addition
Alteration / Renovation
Exterior Work
Misc. Electrical
NEW SINGLE DWELLING
REC ROOM
ADDITION TO SINGLE DWELLING
GARAGE / ACC. STRUCTURE
OTHER (specify below)
AIR CONDITIONER
POOL / HOT TUB
DECK / PATIO / LANDING
SOLAR PV INSTALLATION
SERVICE ONLY
FIRE REPAIR
REPAIR
ADDITIONAL WIRING
OTHER (specify below)
REWIRE
ft2
INDICATE SIZE
(circle units)
NUMBER OF AFFECTED
FLOORS
________________
___________________m2
SERVICE DETAILS: (For combination service entrance panelboards, enter appropriate value in “service size”)
125A
SERVICE CONNECTION REQUIRED?
SERVICE SIZE
100A
OVER 400 AMPS*
TEMPORARY SERVICE?
200A
400A*
INSTALLATION DETAILS: (enter quantities below)
LIGHTS & RECEPTACLES
ADDITIONAL PANELBOARDS
HEATING/COOLING EQUIPMENT
Light Fixtures
100 Amps
Electric Furnace ________kW
15 Amp Switches
125 Amps
Electric Heaters not > 2 kW
15 Amp Receptacles
200 Amps
Electric Heaters > 2 kW to 5 kW
20 Amp Receptacles
Other ___________Amps
Fuel Burning Equipment
30 Amp Receptacles
50 Amp Receptacles
LIFE/HEALTH SAFETY DEVICES
Electric Hot Water Tank ____kW
OTHER EQUIPMENT
Air Conditioner not > 1 HP
Electric Cooking Appliance
Air Conditioner > 1 HP to 5 HP
Motors
Air Conditioner > 5 HP to 25 HP
Smoke Alarms
Sump Pump
CO Alarms
Pool
Combo Smoke/CO
Hot Tub
Fire Alarm System
Generator
SOLAR PV INSTALLATION**
(Enter values for entire array)
Volts DC
Size (kW)
Grid Connected System?
Roof Mounted
Stand-Alone
Yes No
WORK OTHER THAN LISTED / DESCRIPTION OF WORK: _________________________________________________________________
__________________________________________________________________________________________________________________
*A drawing is required to be submitted for plan review for electrical services and panels 400A and larger.
**A licenced electrical contractor is required for a solar PV installation; homeowner applicant not permitted. Plan review (drawings) req’d.
***DECLARED VALUE FORM ON BACK***
Please submit this completed form along with the completed Declared Value Form
to the Zoning & Permits Branch, Unit 31 - 30 Fort Street or fax to 204-986-6347
REVISED: August 1, 2016
Housing Electrical Permit Application Form
Planning, Property and Development Department
Unit 31 • 30 Fort Street • Winnipeg Manitoba R3C 4X7
Declaration of Value
The Winnipeg Building By-law 14.2.3 (5) states:
Every person responsible, architect, professional engineer, contractor or builder, having
contracted for or having performed, supervised or inspected any work of construction,
alteration or repairs on any land, or the agent of such person, shall give, in writing over his
signature when requested by the designated employee all the information in his power
with respect to the cost of the work.
DECLARATION
I have read the above noted items and to the best of my knowledge, the total monetary worth of the work
for which this application is made is the sum of $ .........................................................................................
(PLEASE PRINT)
Name: ______________________________________________________________________________
Company Name: ______________________________________________________________________
Signed: ______________________________________
Date: ______________________________
NOTE: TO BE FORWARDED TO DEPARTMENT AUDITOR
(Office Use Only)
REFERENCE FOLDER:
Please Note: The “declared value” set out above will be provided as information for Statistics Canada. It
is a Federal Offence to submit false information to Statistics Canada.