Building Permit Application
Permit no.
Permit Fee
Date Permit Issued
Receipt No.
Issued By
(74-80)
Day (37-38)
Mo. (39-40) Year (41-42)
$
LOCATION OF IMPROVEMENT
Address - - Street No. (1--6)
Street Name (8--32) Street Type
Fire (45-46)
Census (47-61)
City (33--34)
County (35--36)
Tax
School (44)
Zip Code
Tract
District
District
District
TAX MAP
SUBDIVISION
Page
Lot NameBlock BlockSection Lot
NAME
MAILING ADDRESS
ZIP CODE TELEPHONE LICENSE NO.
SELECTED CHARACTERISTICS OF WORK
DESCRIPTION OF WORK
NATURE OF WORK
DIMENSIONS
1. Number of Floors
1. New Building (52)
2. Total Floor Area of New
2. Addition
3. Alteration
4. Repair/Replacement
Sq. Ft.
5. Demolition
6. Moving/Relocation
Heated
7. Foundation Only
Basement
OWNERSHIP (53)
Accessory
Structures
1. Private (individual,
3. Land Area
Sq. Ft.
Corporation, Other)
2. Public (Federal State,
Local Gov'ts., Other)
ESTIMATED DATE OF COMPLETION
, 20__
PROPOSED USE (IF DEMOLITION INDICATE MOST RECENT USE)
OFF STREET PARKING
Number
1. Indoor
TYPE OF OCCURRENCE (54) UNITS (56-58)IF RESIDENTIAL (55)
Number
2. Outdoor
1
1. One Family
1. Assembly
3. Total
1
2. Mobile Home
2. Business
2
3. Duplex
3. Educational
4. Hazardous
4. Apartment
SINGLE FAMILY ONLY
5. Condominium
5. Factory - - Industrial
Rooms Number
Bedrooms (59)
6. Institutional
6. Dorm/ Rooming House
Bathrooms--Full (60)
7. Mercantile
7. Other (Specify)
Bathrooms-Partial (61)
8. Residential
Total Rooms (62)
If Conversion, Explain
9. Storage
VALUE
CONTRACTOR
TYPE OF WORK
PRINCIPAL HEATING FUEL (63)PRINCIPAL TYPE OF FRAME
Building
Type 1 - Fireproof
Electrical
Type 2 - Fire Resistant
5. Wood
Plumbing
Type 3 - Heavy Timber
6. Other (Specify)
Heating
Type 4 - Non-Combustible
Air Conditioning
Type 5 - Ordinary Construction
Other
Type 6 - Wood Frame
(Excluding Land)
SOURCE OF WATER SUPPLY
TOTAL (64-71)
SOURCE OF SEWAGE DISPOSAL (Permit No.)
Construction Based on
Exterior Dimensions
3. Electricity
1. Gas
2. Oil
4. Coal
First Floor Elevation Above Mean Sea Level
Feet
Elevation of 100 Year Flood
Feet
1. No work will be started before permit card is posted or continued if the permit card is destroyed, lost or stolen.
2. No work is to be continued if permit card is destroyed, lost, or stolen.
3. Contractor and subcontractors will secure (if required) a business license before beginning any work.
4. This permit is void if job is not started within 6 months of application date.
5. I will be, responsible and will pay for the business license of any contractor or subcontractor doing work on this project if found
without a license.
6. The undersigned owner or agent understands that the approval of this application does not constitute a privilege to violate any applicable
governmental ordinances, codes, or laws, and that any omission of or misrepresentation of fact with or without intention of the undersigned or any
alteration or change from this application without approval of the Building Official, shall constitute sufficient ground for the
revocation of any permit issued which was based on the approval of this application. This permit does not authorize any encroachment
upon public property.
Date
Signature of Applicant
Address
FLOOD PLAIN DATA - COMPLETE ONLY IF SITE WITHIN 100 YEAR FLOOD PLAIN
Zoning Approval
Subdivision Approval
Storm Drainage Approval
AFFIDAVIT OF APPLICANT
OWNER
ARCHITECT
GEN. CONTRACTOR
