Version 10/01/2017
TOWN OF CLAYTON
Engineering & Inspections
111 E. Second St., P.O. Box 879
Clayton, NC 27528
Phone: 919-553-5002
Fax: 919-553-1720
Complete this form whenever you wish to change a contractor listed on the original permit and there is no change
to the scope of work.
Application Fee: $50.00 per trade
PROJECT ADDRESS
SUBDIVISION
LOT #
PERMIT HOLDER
PERMIT #
CONTACT PERSON
PHONE & EMAIL
GENERAL
ADDRESS
LICENSE #
PHONE #
ELECTRIC
ADDRESS
LICENSE #
PHONE #
PLUMBING
ADDRESS
LICENSE #
PHONE #
MECHANICAL ADDRESS
LICENSE #
PHONE #
OTHER
ADDRESS
LICENSE #
PHONE #
The undersigned does hereby declare that I have the authority to make the above changes and the information
given above is correct. I agree to comply with all state and local law, local ordinances and regulations, and the
N.C. State Building Code.
APPLICANT’S SIGNATURE
PRINT APPLICANT'S NAME
DATE
OWNER / AGENT STATEMENT
CONTRACTOR(S) TO BE CHANGED
CHANGE OF CONTRACTOR(S)
click to sign
signature
click to edit
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