HOMEOWNER DECLARATION FORM
The undersigned hereby applies for consideration as a property owner desiring to perform construction on his/her
residence. In making this request for a “home owner” permit, the undersigned states the following to be true:
1.
Applicant resides or intends to reside on premises. Property described in permit application is currently owned
by applicant. Applicant has not made a previous Homeowner Declaration where he/she has failed to reside at
the premises thereafter.
2.
Applicant will serve as the building contractor and accept inherent responsibilities for the work authorized by the
approved permit.
3.
Applicant agrees to hire properly licensed contractors for work that is
further
sub
-contracted.
All
plumbing,
electrical
and
HVAC
work
will
require separate sub-contractor forms, including work performed by applicant in
lieu of licensed contractors.
4.
Applicant agrees to perform all work in accordance with all applicable c
odes and
strictly
adhere
to
the i
nspection
requirements.
The
unders
igned
acknowledges that all required inspections must be performed in an established
sequence and that any work done in violation of the
codes must be corrected or may be ordered to be removed.
5.
Applicant acknowledges that he/she is aware that a permit issued under the provisions of the code may be
revoked for
false statements or misrepresentation as to the material fact in the application on which the permit
was based.
6.
Applicant further acknowledges that he/she is aware that any knowingly false statements made in the permit
application will subject said applicant to possible prosecution. Georgia Criminal Code, Section 1610-71
(False Swearing).
APPLICANT'S NAME: _____________________ APPLICANT'S SIGNATURE: _____________________ DATE: ____________
PROPERTY ADDRESS: __________________________________________________________________________
TYPE OF WORK TO BE PERFORMED:
ELECTRICAL
HVAC
GAS
City of Chamblee Planning & Development Department
5576 Peachtree Rd, Ste 102 Chamblee, GA 30341 770-986-5010 chambleega.gov
CHECK ALL THAT APPLICANT IS RESPONSIBLE FOR:
PLUMBING
LOW VOLTAGE
BUILDING
Rev 02/18/2020
OTHER: _______________________
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signature
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