APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
APPLICANT INSTRUCTIONS: For all applications, complete Parts 1 2, 3, 4 and 5 of th’s form. If ei...
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
APPLICANT INSTRUCTIONS: For all applications, complete Parts 1 2, 3, 4 and 5 of th’s form. If eiectricai ,vork, complete also Part 6. If plumbing work, complete also Part 7. Ii mechanical work complete also Part 8. For other permits. complete also Part 9 Ste Plan (Part 10) s to be shown on Page 4 or attached hereto. Parts 11-18 (Pages 5 and 6) are for department use only.
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1. PROPERTY INFORMATiON 3”s’
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2. OWNER INFORMATION
3. CONTRACTORS INFORMATION
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NAME OF CONTRACTOR
ST. ADDRESS
A,.4MEFSNAME
Apphcant (not owner)
CITY. ST.
LICENSE NO.
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——
—
— —__________
Architect Engineer eneral
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Excavation Concrete entW
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Electrical Plumbing -
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Sewer i
Mechanical
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4. CERTIFICATION
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at a rr carer & e ,rd the arre or arty th rt’e orr ad i k s u’oc zed :ha w’ ‘ rd od t at 3otozec o “e o’” ‘C “9ae ‘s arcCo’ “0 i”Y’ZeC 2”’ a”” oo’ea ‘c”'’ a ao. care aas “S oCo’c- ra:e”-’’ 4 ‘c’-oec”he’ er” ‘o’c” -s— :‘‘y”a”e” a-h-a or oh’ I ara -c a c a ‘a c-i ‘h CCI
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5. BUILDING PERMIT APPLICATION Req.iestPnNo 4ss’ert Nt
Use Oily
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NEW CONSTRUCTION (1) ADDiTION (2>
..
ATERAT!ON (3)
EL EL EL
REPAIR
El El
GRADES 12 (7) DAY CARE FAC L TV (8) FACTORY MODERATE HAZARD (9> LOW hAZARD (10)
RELOCAT1ON (6)
CHANGE OF USE ONLY (8)
El
EL El
—
STORAGE MODERATE HAZARD (22) LOW HAZARD (23)
HIGH HAZARD (11)
check that applicabie)
Masonry (21
PUBUC UTILITI HPM
.
REP.ACEMENT (4>
Steel (1)
MERCANTILE (15)
RESIDENTIAL — HOTEL MOTEL (16) MULT FAMILY (17) BOCA TVdO AMlLY (18) CABO TWO FAMILY (19) BOCA S NGLE FAMILY (20> CABO SINGLE FAMILY (21>
BUSINESS (6)
DEMOLIT ON (5>
Structural Frame
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EDUCATIONAL
FOUNDATION ONLY (7)
EL
OTHER (24) PARKING GARAGE CARPORT MOTOR FUEL SERV REPAIR GARAGE
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IMPROVEMENT TYPE:
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INSTITUTIONAL GROUP HOME (12) HOSPITAL (13) L. I JAIL (14)
ASSEMBLY THEATRE (1) J NIGHT CLUB (2> RESTAURANT (3> CHURCH (4) OTHER ASSEMBLI (5)
Piar NL-rer
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PROPOSED USE:
Exterior Walls
Concrete (3)
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Other (5), Identify
Check those apphcabie)
Steel (1)
Wood (4)
Masonry (2)
.
EL
Concrete 3)
El
Other (5), Idertfy
Wood (4)
..
Street Frontage (Feet>
Stones (Number)
Front Setback (Feet)
Bed Rooms (Number)
Rear Setback (Feet)
Full Baths (Number)
Parking Area (Sq. feet)
Left Setback (Feet)
Partial Baths (Number)
Living Area (Sq. feet)
Right Setback iFeet)
Garages (Number)
Basement Area (Sq. feet)
Height Above Grade (Feet)
Windows (Number)
Garage Area Sq. feet)
New Residential Units (Number)
Fireplaces (Number)
OfficeiSales (Sq. feet)
Lot Area (Sq. (eel) Building Area Sq. feet)
-
Existing Residential Units (Number)
—
Elevators I Escalator (Number)
/
Est. Start
Outside Parking (Number) /...._
/
Est. Finish
Manufacturing (Sq. feet) Building Est. Value $
/
6. ELECTRICAL PERMIT APPLICATION ThtaiSerce
AMPS
N...icercfCrcLs. .2MPE
POWER DEVICES
-
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—
— ..
— -.
Electrical Work
3WiRE4v’iIPE
No OUTPUT LOAD
—
-
-
u”LeofServceC:ets_
POWER DEVICES
—
—
Yes
No 2Lvj
No. OUTPUT LOAD I
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7. PLUMBING PERMIT APPLICATION
Plumbing Work E Yes
Enter the Number of Fixtures Being Installed, Replaced or Repaired Dnnk ng Fcantains
Lavator es t
*
—
Back Flow Preventers t
Shower Sta S
——
Foor Drans
Vater Pumps
Water Heaters
Root Open ngs
—
Parkrg Lot Drains
Unals
Sewage Ejectors
Ins de Donspouts
Sump Pumps
—
—
*
Sw mm ng Poo a
-4
Standptpes iYN N.iber Hose Outletsj re Spr nklers V N Number of Heads) Lawn Spr nklers V N) Number of Heads)
Grease Traps B dets
D shwashers
—
—
Water Softeners
LLaun&v rubs
—
—
To lets
Snks
No
Garbage D sposa a
Totat Fxtures Pubic Sewer IV N
Public dater V N Water Service Size
IN
Water Meter Size
——
Avg Daily Water Use
IN
GPD
Utility Service Revisions Eat Start
—
L
/
Plumbing Work Est Value $
/ 8. MECHANICAL PERMIT APPLICATION Est Finish
Mechanical Work Li Yes
i No
Enter Number of New or Replacement Units --
S
--5--—--—
Forced Air Furnace
---—
S____—-
erato_
Unit Heater
Boiler
Gas/Oil Conversion
Heat
I
Space Heater
Air Cleaner
—
—
Window A C Unit
Gredty Furnace
Split System A/C
Solid Fuel Appliance
A/C Compressor
p_
Kitchen Exhaust Hood
j
Hazardous Exhaust System Electric Furnace
I
Utility Service Revisions
Type of Heating Fuel (pheck One)
Gas (1)
Oil (2)
E
Electric (3)
D
Coal (4)
Wood (5) Mechanical Work
9. OTHER REQUIRED PERMIT APPLICATION(S) Per De
ye
D
Other (6)
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10. SITE PLAN (Show lot lines, easements and work layout and dimensions)
SCALE
1 Inch
FEET
PAGES 5 AND 6 ARE FOR DEPARTMENT USE ONLY
11. DATA ENTRY tion Received:
/
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Data Entri:
/ -
12. FLOODPLAIN EVALUATION FLOOD MAP NUMBER & DATE
LOWEST FLOOR ELEVATION
FLOOD ZONE
BASE FLOOD ELEVATION
—-
13. ZONING PLAN EVALUATION ZOMNG DISTRICT
MAP NUMBER
—
LOT AREA (From Page 2)_
LOT COVERAGE
—
LOT AREA PER ROOM
()
ENCROACHMENTS
—
—
OFF STREET PARKING SPACES, REQUIRED PROVIDED LOADING SPACE
____ —
SIGNS; NUMBER_____________________
SIZE OF EACH SIGN
PLANN ING COMMISSION APPROVAL REQUIRED____ BOARD OF ZONING APPEALS APPROVAL REQUIRED
