U.C.C.F102‐1
Main Facility Block: ________ Lot: ________ Municipality: ____________________ Permit No: ________
APPLICATION FOR ANNUAL PERMIT
1. Name and address of owner:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. The buildings, street addresses (including blocks and lots), to be covered by this annual permit are: (attach
sheet(s) if necessary)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. The annual permit records will be maintained at:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. List full time maintenance staff at the facility for each subcode (see page 2, or attach list).
5. List the names of at least one, but not more than three, individuals per subcode who are required to
complete five hours of continuing education per year (see page 2, or attach list).
6. Person who will be responsible for the maintenance logs, job assignments, and quality control:
Name___________________________________________ Title__________________________________
Telephone_______________________________ Email_________________________________________
7. I attest that maintenance staff performing work under the annual permit are under the direct supervision of a
qualified individual, as set forth in N.J.A.C. 5:23-2.14(e)1, or are individually qualified in their respective trades.
Please initial to confirm: ________
8. I attest that procedures are developed to provide training on the Uniform Construction Code and adopted
subcodes. This training is done on a regular basis. Please initial to confirm: ________
9. Attach to this application an explanation of the procedures that the applicant uses to ensure proper quality
control of the work performed under the annual permit.
10. Fees:
State fees
N.J.A.C. 5:23-4.20(c)5ii
● One to 25 workers (including forepersons): $933.00 per worker
● Each additional worker over 25: $329.00 per worker
● Training registration fee of $196.00 per subcode; max of $588
Local fees:
N.J.A.C. 5:23-4.18(a)5
● Training registration fee of $140 per subcode
● Annual permit fee: __________________
(determined by local ordinance)
