Land Disturbance Permit Application
Permit Number: _________________
Issued by City of Chamblee
Rev 1/27/17
City of Chamblee Development Department
3506 Broad St. • Chamblee, GA 30341 • 770-986-5024• chambleega.gov
City of Chamblee Planning & Development Department
5576 Peachtree Rd, Ste 102 • Chamblee, GA 30341 770-986-5010 chambleega.gov
Job Address:
City:
State:
Zip:
Project Name:
Tax PIN #:
Zoning District:
Total Lot Area:
Total Disturbed area:
Scope of work:
Routing Information (Please check all that apply to your project. Responses determine how your project is routed. Incorrect or
incomplete information could result in delays to your plan review):
Pool New roads New tenant spaces or changes to addressing Work affecting sewer capacity Retaining walls > 4’
Tree removal Work affecting State Road Work affecting County Road Work affecting City Road > 1 acre disturbed
Property Owner (of Job Address):
Name:
Applicant: Company
Name: Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Tel #:
Mobile #:
Tel #:
Mobile #:
E-Mail:
E-Mail:
Notice: No changes shall be made from that which is stated in this application, or in attached plans and specifications, except by submitting a revised
application, plans and/or specifications and receiving approval of the land development manager Official for such change. Granting of a permit shall not
be construed as a permit for or an approval of any violation of the UDO or any other state or local law regulating construction or the performance of
construction. I hereby certify that I have read and examined this application and the information provided is true and correct. I further certify that all
construction will comply with the current City and State Building Codes. This permit is void if no construction activity commences within six months of
issuance date or is work is not complete within two years of issuance.
I further agree that I shall be responsible from the date of this permit, or from the time of the beginning of the first work, whichever shall be earlier, for all
injury or damage of any kind resulting from this work, whether from basic services or additional services, to person or property. I agree to exonerate,
indemnify and save harmless the city from and against all claims or actions, and all expenses incidental to the defense of any such claims, litigation and
actions, based upon or arising out of damage or injury (including death) to persons or property caused by or sustained in connection with any work
performed under the building permit issued as a result of this application. I also agree to allow all inspections and right of entry per Section 120-2 of the
UDO.
Signature of Applicant: __________________________________________________________________ Date: _____________________________
Signature of Property Owner: _____________________________________________________________ Date: _____________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome