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BuildingApplication - Building Application Draft Revision 3

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U.S.A. forms for City of Bridgeport

BROWSE CITY OF BRIDGEPORT (CT) FORMS

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CITYOFBRIDGEPORT,BUILDINGDEPARTMENT

BUILDINGPERMITAPPLICATION

PermitNo.______________ ReceiptNo._____________DateIssued____________  SpecialConditionsonRear

FEESBuildingFee _____________

OccupancyFee_____________

 FullFee Total_____________

BuildingDept.Est.ofValue ______________

ApplicantValueofWork_______________

ThisSectionToBeCompletelyFilledOutByApplicant

ToErect

SiteAddress

OwnerName

OwnerAddress____________________________________City/Town_____________________State:________Zip:________________

Telephone Email:

PrimeContractor

Address__________________________________________City/Town_____________________State:________Zip:________________

Phone Email:

Architect‐Engineer CtRegistrationNo.

Address__________________________________________City/Town_____________________State:________Zip:________________

Phone Email:

MailPermitto:Name______________________________Email_____________________________

Address_________________________________________City_________________State_____Zip__________Phone___________

TYPEOFCONSTRUCTION

ExteriorWalls Floors/Roof InteriorFrame

 CombustibleNonCombustible  CombustibleNonCombustible CombustibleNonCombustible

USEGROUP(S)

RESIDENTIAL

 OneFamilyTwofamilyThreeormorefamily#______UnitsHotel‐MoteI‐RoomingHouseGarage_____Cars

SWIMMINGPOOL

 Private(IFamilyDwelling)  Public(StateHealthDept.approvalrequired)  ShedorOther

NON‐RESIDENTIAL

 Assembly,Church,Restaurant,etc.Office,Bank,ProfessionalEducational12thGradeorlessIndustrial

 InstitutionalMercantile,Stores,etc.ParkingGarageServiceStationStorageOther______________

Changeofuse:________________

New:__________________

Existing:_______________

DescribeWorkToBeDoneFully:

ThisSectionToBeFilledOutByCity

FloodZone UseGroup FloorLoad FireGrading Occup.Load TypeConst. CodeVersion

Dimensions

Length Width Height Stories Area

NewConst.

Existing

Sprinklers Required  HazardClass WaterDemand:PSI,____________GPM,_______________

ZONINGAPPROVAL

Block___Lot___

 ZBA

 ZoningComm

ission

HEALTHDEPAR

TMENT FIREMARSHAL

ENGINEERINGAPPROVAL

FloodZone

Sanitary

Comb.

Storm

 DEEP

 HISTORICALDISTRICT

HOLDHARMLESS/RELEASE

CityofBridgeportandBridgeportBuildingDepartmentrequirethatpermiteeshallindemnifyandhold‐harmless"City/Department",itsemployeesandagentsandreleasebothfromanyand

allclaimsoractionsbroughtbythirdpartiesforinjuriesordamagesofpropertyinconnectionwithgrantingofthispermitandworktobeperformedthereun

der.Permitteemayberequired

toinsureagainstsuchclaimsinamountsappropriatetomeetsuchobligation.City/Departmentshallhavetherighttoreviewandspecifysuchamountandscopeofcoverageasitmaydeem

appropriateforactivitiesconductedunderthispermit.

The owneracting herein by andthrough his agent,lic

ensedEngineeror Architect ofthe abovedescribedpropertyhereby approvesthisapplication andagrees to complywithall

appropriatestatutesoftheStateofConnecticutandallregulationsoftheConnecticutStateBuildingCodeandtodoworknotspecificallycoveredbythisapplication.

"Ideclar

eunderpenaltiesofperjurythatthisapplication,includinganyaccompanyingplans,specifications,etc.,hasbeenexaminedbymeandtothebestofmyknowledgeand

beliefisatrue,correctandcompletestatementoftheworktobecoveredbythisapplication,theproposedworkisauthorizedbytheown

erinfeeandapplicantisauthorizedtomakesuch

application,andthatIamtheagent,LicensedEngineer,orArchitectemployedby

SignatureofOwnerorAuthorizedAgent_________________________________PrintName_____________________________Date__________

StreetAddress___________________________________City_______________________State__________Zip_______

Phone__________________________Email_________________________________________



Form361(4.6.20)

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Completed 11 July 2020

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