BLOCK _____________ LOT ______________ QUALIFICATION CODE _______________ ADDRESS (SITE) _________________________________ PERMIT NO. ______________________
CONSTRUCTION PERMIT
APPLICATION
Applicant Completes: Sections I, II, III (optional), IV, VI, and VII
U.C.C. F100-1 (rev. 8/08)
V. FEE SUMMARY (for office use only)
$
1. Number of Stories
VI. BUILDING/SITE CHARACTERISTICS
(office use only)
3. Area — Largest Floor sq. ft.
4. New Building Area sq. ft.
5. Volume of New Structure cu. ft.
ft.
2. Height of Structure
VII. DESCRIPTION OF BUILDING USE
A. RESIDENTIAL (primary use)
1. State Specific Use:
2. Use Group, Proposed:
3. Change in Use Group, Indicate Present:
4. No. of dwelling units:
Gained, Sale
Gained, Rental
Lost, Sale
Lost, Rental
B. NON-RESIDENTIAL (primary use)
1. State Specific Use:
2. Use Group, Proposed:
3. Change in Use Group, Indicate Present:
C. MIXED USE -List secondary use(s):
D. Construct. Classification:
1.
2.
3.
IV. DOES OR WILL YOUR BUILDING CONTAIN ANY OF THE FOLLOWING?
UpdateUpdate
8. Subtotal $
10. Subtotal
$
11. Cert. of Occupancy
12.
Other
13.
TOTAL $
1. Building $
2.
Electrical
3.
Plumbing
4.
Fire Protection
Elevator Devices
5.
6. Subtotal
7.
Less 20% for State Plan Review
9.
State Permit Surcharge Fee
7. Max. Occupancy Load
6. Max. Live Load
IIa.PROPOSED WORK
DO YOU WANT:
IIb. SUBCODES
(Check all that apply)
1. Partial Releases
2. Prototype Processing
III. PLAN REVIEW (optional)
TOTAL COST
Plans
Rec'd by
Date
Rec'd
Rejection
Date
Approval
Date
Re-
viewer
Resubmission Dates
Approval Rejection
Re-
viewer
Est. Cost
Minor Work New Building Addition Demolition
Repair Alteration Renovation Reconstruction
Asbestos Abat. -Subch. 8 Lead Hazard Abatement Radon Remediation Annual Permit
8.
If Industrialized Building:
State Approved
HUD
9.
Total Land Area Disturbed sq. ft.
10. Flood Hazard Zone
11.
Base Flood Elevation
ft.
12. Wetlands yes
no
Total Units
Income-restricted
Proposed
Present
1. Elevators/Escalators/Lifts/
Dumbwaiters/Moving Walks
2. High Pressure Boilers
3. Pressure Vessels
4. Refrigeration Systems
5. Cross-Connections/Backflow Preventers
6. Hazardous Uses/Places of Assembly
7. Sprinklers/Standpipes
8. Smoke Control Systems in Open Wells
9. Underground Storage Tanks
10. Swimming Pools, Spas and Hot Tubs
11. LPGas Tanks
12. Fire Alarm
Building
Electrical
Plumbing
Fire Protection
Elevator
FOR OFFICE USE ONLY (Optional)
6. Responsible Person in Charge once Work has Begun
FAX:
Tel.
5.
Architect or Engineer
Contact
FAX:
Address
Tel.
e-mail
License No. OR, if new home, Builder Reg. No. Exp. Date
Home Improvement Contractor Registration No. or Exemption Reason
Federal Emp. ID No.
FAX:
PrivatePublicOwnership in Fee:
zip codemunicipalitystreet
Address
Tel.Principal Contractor:4.
Address
e-mail
I. IDENTIFICATION
Proposed Work Site at:
Name of Owner in Fee:
Tel.
e-mail
- Use List Link -
$0
CERTIFICATION IN LIEU OF OATH
I. OWNER SECTION (to be completed if the applicant is the owner in fee)
I hereby certify that I am the owner in fee of the property listed on Page 1.
Mark the following applicable boxes:
A. ( ) I further certify that a new home (private residence) will be constructed on this property for my own use and occu-
pancy. This dwelling is to be occupied by myself and is not to be used for any purpose other than single family
residential use. I attest that all construction, plumbing, or electrical work will be done, in whole or in part, by me or by
subcontractors under my supervision, in accordance with all applicable laws; and, I further acknowledge that said
new home is not covered under the New Home Warranty and Builders Registration Act (N.J.S.A. 46:3B-1 et seq.) and
that such fact shall be disclosed to any person purchasing this property within ten years of the date of issuance of a
certificate of occupancy.
I UNDERSTAND THAT IN MARKING BOX A, I ACKNOWLEDGE THAT I AM ASSUMING RESPONSIBILITY FOR
THE WORK DONE ON SAID PROPERTY, THE CONDITION OF THE PROPERTY PRIOR TO, DURING, AND AFTER
ANY WORK PERFORMED, AND FOR THE PERFORMANCE OF THE SUBCONTRACTORS I HIRE, EMPLOY, OR
OTHERWISE CONTRACT OR WITH WHOM I MAKE AGREEMENTS TO PERFORM WORK. I AM VOLUNTARILY
AND KNOWINGLY ASSUMING THIS RESPONSIBILITY.
B. ( ) I further certify the following as required by the New Jersey Uniform Construction Code, N.J.A.C. 5:23-2.15(f)1.ix:
I personally prepared the plans submitted for: 1) the new home referred to in A.; or, 2) an addition, alteration, renova-
tion, or repair to an existing single family residence owned and occupied by myself and located on the property listed
on Page 1; or, 3) a new structure that will be physically separate from, but that will be deemed part of, an existing
single family residence that is owned and occupied by myself and located on the property listed on Page 1.
C. ( ) I further certify that I will perform or supervise the following work:
C.1. ( ) Building C.2. ( ) Fire Protection
I further certify that I will perform the following work:
C.3. ( ) Electrical C.4. ( ) Plumbing
D. ( ) I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of
Taxation and to comply with all New Jersey tax laws.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals have been given, including such certification as the construction official may require.
I understand that if any of the above statements are willfully false, I am subject to punishment.
Signature_____________________________________________________________ Date _______________________
II. AGENT SECTION (to be completed if the applicant is not the owner in fee)
I hereby certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(d): the proposed work is autho-
rized by the owner in fee; and I have been authorized by the owner in fee to make this application as his agent.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals have been given, including such certification as the construction official may require.
I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of Taxation
and to comply with all New Jersey tax laws.
I understand that if any of the above statements are willfully false, I am subject to punishment.
( ) Check if contractor.
Agent Name _________________________________________________________________________________________
Address _____________________________________________________________________________________________
___________________________________________________________________________________________________
Telephone ___________________________
Signature____________________________________________________________________________________________
III. ( ) LEAD HAZARD ABATEMENT: Include Homeowner or Building Owner Affidavit as per N.J.A.C. 5:17.
U.C.C. F100-2 (rev. 5/2007)
LOCAL
APPROVAL
COUNTY
APPROVAL
REGIONAL
APPROVAL
STATE
APPROVAL
COMMENTS
Prelimin.
Initial
Prelimin.
Initial
Prelimin.
Initial
Prelimin.
Initial
Final
Date
Final
Date
Final
Date
Final
Date
OFFICE DATE RECEIVED: ______________________________
VIII. PRIOR
APPROVALS
CHECKLIST
(office use only)
Zoning Officer
Planning Board
Zoning Board
Sewer Authority
Water Authority
Police Department
Health Department
Soil Conservation
N.J. Department of
Community Affairs
N.J. Department of
Transportation
N.J. Department of
Environmental Protection
Utility Dig No.
U.C.C. F100-3 (rev. 12/07)
IX. SUBCODES AND SPECIAL REGULATIONS APPLICABLE (office use only—optional)
Name of Code & Edition Name of Code & Edition
Building ___________________________________________ Energy ____________________________________________ Other______________________________________________
Electrical___________________________________________ Barrier Free ________________________________________ __________________________________________________
Plumbing __________________________________________ Flood Hazard _______________________________________ __________________________________________________
Fire Protection ______________________________________ As Built Elevation Cert. _______________________________ __________________________________________________
Mechanical _________________________________________ Other _____________________________________________ __________________________________________________
X. CERTIFICATES ISSUED (office use only) DATE ISSUED DATE EXPIRED DATE REISSUED DATE EXPIRED
Temporary Certificate of Occupancy No. __________ ___________________ ___________________ __________________ ___________________
Temporary Certificate of Compliance No. __________ ___________________ ___________________ __________________ ___________________
Continued Certificate of Occupancy No. __________ ___________________ ___________________ __________________ ___________________
Certificate of Compliance No. __________ ___________________ ___________________ __________________ ___________________
Certificate of Occupancy No. __________ ___________________ ___________________
Certificate of Approval No. __________ ___________________ ___________________
Lead Abatement Clearance Certificate No. __________ ___________________ ___________________ __________________ ___________________
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