App. Date: Type Permit
Building Electrial Plumbing Owner Applicant?
Mechanical Other Y N
Apt. Zip
Parcel Number
Lot Number Residential Industrial
Commercial Other
State Zip
Cell Phone
City
State Zip
Applicant (not owner
Architect I Engineer
General Contractor
Excavation
Concrete
Carpentry
Electrical
Plumbing
Sewer
Mechanical
Roofing
Masonry
Drywall or Lathing
Insulation
Paving
Fire Sprinkler
Signature of Applicant Email Phone No.
Responsible Person in Charge of Work & Email
Phone No.
Parcel Type
Phone Number
Owner Information
Street Address
City
Last Name or Business Name & EMAIL ADRESS
CONTRACTORS INFORMATION
Contractor Name Email Address
I hereby certify that I am the owner of record of the named property, or that the proposed work is authorized by
the owner of record and that I have been authorized by the owner to make this application as his authorized
agent and I agree to conform to all applicable laws of this jurisdiction. In addition, if a permit for work described in
this application is issued, I certify that the code official or the code official's authorized representative shall have
the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the
code(s) applicable to such permit.
PROPERTY INFORMATION
CERTIFICATION
Fax No.
First Name
and 5 of this form. If electrical work, also complete Part 6. If plumbing work,
oomplete also Part 7. If mechanical work, complete also Part 8. For other
permits, complete also Part 9. Site Plan (Part 10) is to be shown on Page 4 or
attached hereto.
Street Address
Subdivision
click to sign
signature
click to edit
Drinking Fountains
Floor Drains
Water Heaters
Water Softeners
Sewage Ejectors
Sump Pumps
Grease Traps
Bidets
Water Service Size Water Meter Size
Forced Air Furnace Incinerator Air Handling Unit
Unit Heater Boiler Heat Pump
Gas / Oil Conversion Coil Unit Air Cleaner
Space Heater Window A/C Unit Kitchen Exhaust Hood
Gravity Furnace Split System A/C Kitchen Exhaust Hood
Solid Fuel Appliance A/C Comptessor Electric Furnace
Type of Heat (check one)
Gas Electric Wood Other
Permit Type:
Separate items(i.e. patio or deck:
Oil
Garbage Disposals
Tubs / Showers
Shower Stalls
Roof Openings
Parking Lot Drains
Inside Downspouts
Swimming Pools
Standpipes (Number of Heads)
Fire Sprinklers (Number o f Heads
Lawn Sprinklers (Number of Heads
Average Daily Water Use (GPD)
Plumbing Work Y N
Total Fixtues
Back Flow Preventers
Est. Start
Total Est. Value
Mechanical Work Y N
Sinks
Laundry Tubs
Dishwashers
Lavatories
Toilets
Urinals
Enter the Number of Fixtures Being Installed, Replaced or Repaired
Water Pumps
Other Permit Items
Enter the Number of New or Replacements Units
Est. Start
Est. Finish
Est. Start
Est. Finish
Utility Service Revisions:
Public Sewer
Public Water
Plumbing Permit Application
Mechanical Permit Application
Number of Bedrooms:
Yes
Yes
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