_______________________________________________________2.___________________________________________________
1.
Address (where work is to be done) Legal Description
3. Applicant Information
APPLICANT
Name
Represents
Mailing
Email Phone #
4. Property Owner Information
OWNER
Complete Mailing Address of Deed Owner:
Name of Individual for Contact
Purposes
Email Phone #
5. General Contractor Information
GENERAL
CONTR.
Company Name, as shown on
City of Salina license
Complete Mailing Address of Contracting Company:
Name of Individual for
Contact Purposes
Email Phone # License #
6.___________________________________________________________________________________________________________
Tenant’s Name and Phone Number, if different from property owner
7. DESCRIBE WORK TO BE DONE - BE SPECIFIC
8. If described work will be done on the primary residential structure (“house & any additions/attachments thereto”), was that
house built prior to 1978? Yes ___ No ___ (
If yes
, Kansas “PRE” applies; CRN &LPA Forms Required)
9. Will the owner-occupant be performing any of the work? Yes ___ No ___ Describe: __________________________________
10. If scope of work is renovation and repairs, indicate total value of labor and materials $______________
11. Will plumbing, mechanical or electrical work be performed? If yes, check box & indicate contractor company name.
MECHANICAL ________________________________ ELECTRICAL ________________________________
Right of Way Concrete ___________________________ PLUMBING____________________________________
• Permits for new residential dwellings are subject to a fee for the water meter pit and meter set. Other fees might also include, but may not be limited
to, a park service area fee. All additional fees are due and payable with the building permit fee at time of issuance of the permit. Please consult with
City staff to confirm the fees that apply to your project.
• I hereby certify that I have read and examined this application and know the same to be true and correct. I hereby certify that I have been authorized
by the owner to act as his agent in applying for and obtaining this permit. 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 presume to give authority to violate or cancel the provisions of any
other state or local law regulating construction or the performance of construction.
12. SIGNATURE OF APPLICANT _________________________________________Date:______________
Accepted by:____________________ Date:__________ Project Number_______________ CRN&LPA Forms Rec’d__________
BLF – 035.1 Rev.3-2015
Application for
Building Permit, Building Services Division
PRINT CLEARLY OR TYPE - Complete Items #1 - #12
click to sign
signature
click to edit
![]()
