Gallatin, Tennessee
Date Applied ______/________/20____
Project Address Suite (if applicable) Subdivision Lot #
Property Owner Mailing Address Phone Email
Mailing Address
Blasting Company requesting permit
State Registration #
Company Mailing Address Phone Email
Blaster in Charge
State Registration #
On-site Contact Person
Cell Phone
Years of Experience
Class/Type of Explosives to be used
Location/Distance to Nearest Building:
By submitting this application, I hereby agree that said operations will be carried out in strict compliance with Gallatin Municipal Ordinance
O1605-37, International Fire Code Section 3307, and Tennessee Code Annotated 68-105 (2015) Tennessee Blasting Standards Act of 1975.
s permit becomes null and void if work or construction authorized is not commenced within 6 months or if construction or work is
suspended or abandoned for a period of 6 months at any time after work in commenced.
In the event the licensed contractor disclosed hereon is replaced on this project, the Gallatin Building Department shall be immediately
notified. Failure to notify may result in revocation of this permit and is a violation of state law.
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and
ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance
of construction. Contractor and/or homeowner/builder is responsible to adhere to all existing setbacks, easements, and/or buffer
yards located on said property.
I hereby certify that I am the:
Owner Owner’s Agent and all official correspondence in connection with this application should
be sent to my attention using the contact information for myself in the abovementioned.
___________________________________________________________ _________________________________
Print or type name here Date
Signature of Owner or Owner’s Authorized Agent
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