BUILDING PERMIT & PLAN EXAMINATION APPLICATION
CITY OF MIDLAND – BUILDING DEPARTMENT
333 W. ELLSWORTH ST., MIDLAND, MI 48640
989-837-3383 Fax 989-835-2378
NOTE: Separate applications must be submitted for plumbing, mechanical, & electrical.
PROJECT ADDRESS ___________________________________________________________________
OWNER ____________________________________________________PHONE__________________
EMAIL_____________________________________________________________________________
CONTRACTOR/ARCHITECT/ENGINEER INFORMATION:
CONTRACTOR_______________________________________________PHONE__________________
ADDRESS/CITY/STATE/ZIP_____________________________________________________________
LICENSE # ________________________________________ EXPIRATION DATE __________________
CELL/ALT. PHONE __________________________________EMAIL ____________________________
ARCHITECT/ENGINEER________________________________________PHONE__________________
ADDRESS/CITY/STATE/ZIP_____________________________________________________________
STATE REGISTRATION # ______________________________EXPIRATION DATE __________________
CELL/ALT. PHONE __________________________________ EMAIL ____________________________
VALUE OF PROJECT __________PROJECT DESCRIPTION _________________________
PRINCIPLE TYPE OF CONSTRUCTION:
RESIDENTIAL: Single Family____ Duplex____ Condo____ New ____ Addition____ Remodel____
COMMERICIAL: New Construction____ Addition____ Remodel____
BEARING WALLS: Masonry____ Wood____ Structural Steel____ Reinforced Concrete____ Other____
FOUNDATION: Crawl____ Full Bsmt____ Slab____ Wood____ Block____ Concrete____ Other____
MISC: # Stories____ Use Group____ Type Construction____ # Occupants____ Fire Sprinklers____
PARKING: # Outdoor Parking____ # Barrier Free Parking____ # Covered Parking____
FLOOR AREA:
Bsmt(finished)______ (unfinished)______ 1
st
Flr______ 2
nd
Flr______ 3
rd
Flr______ Garage_______
HOMEOWNER AFFIDAVIT: (if permit is under homeowner’s name)
I hereby certify the project work described on this permit application shall be installed by myself in my own home in
which I am living in or about to occupy. All work shall be installed in accordance with the Michigan Building Code and shall
not be enclosed, covered up, or put into operation until it has been inspected and approved by the City Building
Inspector. I will cooperate with the City Building Inspector and assume the responsibility to arrange for necessary
inspections. Deed restrictions may apply to this property. This City of Midland permit does not supersede or void any
such restrictions. It is the property owner’s responsibility to properly comply with deed requirements.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED. I HEREBY CERTIFY THAT I HAVE READ
THIS APPLICATION AND 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 GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE
OR LOCAL LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
SECTION 23a OF THE CONSTRUCTION CODE ACT OF 1972, 1972 PA 230, MCL 125.1523A, PROHIBITS A PERSON FROM CONSPIRING TO CIRCUMVENT
THE LICENSING REQUIREMENTS OF THIS STATE RELATING TO PERSONS WHO ARE TO PERFORM WORK ON A RESIDENTIAL BUILDING OR RESIDENTIAL
STRUCTURE. VIOLATORS OF SECTION 23a ARE SUBJECTED TO CIVIL FINES.
SIGNATURE OF HOMEOWNER OR DESIGNATED AGENT______________________________________________
(Homeowner signature indicates compliance with Homeowner Affidavit)
PRINTED NAME_________________________________________________DATE________________________
Rev 10/2015
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signature
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