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________________

Basement___ Modular___

Other _______________________________________________________________________________

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________________