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.