Site Address__________________________________________________________________________________

Subdivision_________________________________________ Lot No. ________ Lot Area _________________

Building setback from property lines: _______ _______ _______ ________

front rear left right

Last or Corporate Name _______________________________________________ First____________________

Mailing Address_____________________________________________________________________________

City__________________ State____ Zip_________ Phone ________________ Cell ________________

General Contractor______________________________________ Phone _______________Cell_______________

Building Description: Area _________ Width ________ Length _______ Height ________

Type of Work: ___ new construction ___ addition ___ alteration

Type of Construction: ___ wood frame ___ steel frame ___ masonry ___ concrete

___ post frame ___ other____________________________

Applicable Sub Codes: ___ building ___ electrical ___ plumbing ___ hvac

I hereby certify that I am the owner of record of the named property, or that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized agent and I agree to conform to all applicable laws of this jurisdiction. In addition, if a permit for work described in this application is issued, I certify that the code official or the code official’s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. I further testify that the above information is true and accurate.

Departmental Approvals: Zoning____________________________________ Date ________________