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PLUMBING PERMIT APPLICATION
CITY OF MIDLAND – BUILDING DEPARTMENT
333 W. ELLSWORTH ST, MIDLAND, MI 48640
989-837-3383
PROJECT ADDRESS __________________________________________________________________
OWNER __________________________________________________PHONE___________________
EMAIL ____________________________________________________________________________
CONTRACTOR INFORMATION
CONTRACTOR______________________________________________PHONE___________________
CONTRACTOR ADDRESS ______________________________________________________________
CITY/STATE/ZIP________________________EMAIL________________________________________
LICENSE # ________________________________________ EXPIRATION DATE __________________
CELL/ALT. PHONE _____________________________________ FAX # _________________________
___________________________________________________________________________________
HOMEOWNER AFFIDAVIT: (if permit is under homeowner’s name)
I hereby certify the plumbing work described on this permit application shall be installed by myself in
my own home in which I am living in or about to occupy. All work shall be installed in accordance with
the Michigan Plumbing Code and shall not be enclosed, covered up, or put into operation until it has
been inspected and approved by the City Plumbing Inspector. I will cooperate with the City Plumbing
Inspector and assume the responsibility to arrange for necessary inspections.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180
DAYS OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER
WORK IS COMMENCED. I HEREBY CERTIFY THAT I HAVE READ THIS APPLICATION AND 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 GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR
LOCAL LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
SECTION 23a OF THE CONSTRUCTION CODE ACT OF 1972, 1972 PA 230, MCL 125.1523A, PROHIBITS A PERSON FROM CONSPIRING TO CIRCUMVENT
THE LICENSING REQUIREMENTS OF THIS STATE RELATING TO PERSONS WHO ARE TO PERFORM WORK ON A RESIDENTIAL BUILDING OR RESIDENTIAL
STRUCTURE. VIOLATORS OF SECTION 23a ARE SUBJECTED TO CIVIL FINES.
SIGNATURE OF OWNER OR CONTRACTOR _______________________________________________________
(Homeowner signature indicates compliance with Homeowner Affidavit)
PRINTED NAME_________________________________________________DATE________________________
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