Apt. 1 T~~~,. I I 3. CONTRACTORS INFORMATION. NAMEOFCONTRACTOR ST. ADDRESS CITY, ST. LICENSE NO. I LAST NAME FlRST NAME 4.
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1 APPLCATON FOR PLAN EXAMNATON AND BULDNG PERMT App / / st Address division First Name Street Address Applicant (not owner) Architect Engineer General Contractor Excavation ncrete Type Permit Building (EL Last name or Business Name APPLCANT NSTRUCTONS: For all applications, complete Parts 1, 2, 3 4 and 5 of this form f electrical work, complete also Part 6 f plumbing work, complete also Part 7 f 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 Parts 1118 (Pages 5 and 6) are for department use only s Owner Z Electrical (E) Plumbing (P) Applicant ~echanical (M) Other (0)(See Rem 9) (Y/N) P PROPERTY NFORMATON Lot Apt Zip 2 OWNER NFORMATON Parcel 1 T~~~, Residential (R) lndushid () Commercial (C) Other (0) 3 CONTRACTORS NFORMATON NAMEOFCONTRACTOR ST ADDRESS CTY, ST LCENSE NO LAST NAME FlRST NAME City Parcel Phone Zoning State Zip 9 5 mentry sewer Plumbing Mechanical Drywall or Lathing Sprinkler Fire Alarm 4 CERTFCATON hereby certify that am the owner of record of the named property, or that the proposed work is authorized by the owner of record and that have been authorized by the owner to make this application as his authorized agent and agree to conform to all applicable laws of this jurisdiction n addition, if a permit for work described in this application is issued, 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 SGNATURE OF APPLCANT ADDRESS PHONE NO RESPONSBLE PERSON N CHARGE OF WORK TTLE PHONE NO o m 2 ~ MERNATONAL 3 CODE COUNCL Page 1 ~ ~
2 p~ p~ For Oept Use Only Plan MPROVEMENT TYPE: RB UBJ Plan ~sjgnmenr (YiN) NEW CONSTRUCTON (1) ADDTON (2) ALTERATON (3) REPAR REPLACEMENT (4) DEMOLTON (5) RELOCATON (6) FOUNDATiON ONLY (7) CHANGE OF USE ONLY (8) Structural (check that applicable) Frame 5 BULDNG PERMT APPLCATON PROPOSED USE: NSTTUTONAL OTHER (24) ASSEMBLY GROUP HOME (12) PARKNG GARAGE THEATRE (1) HOSPTAL (13) CARPORT NGHT CLUB (2) JAL (14) MOTOR FUEL SERV RESTAURANT (3) MERCANTLE (15) REPAR GARAGE CHURCH (4) PUBLC UTLTY RESDENTAL OTHER ASSEMBLY (5) HPM HOTEL, MOTEL (16) BUSNESS (6) MULTFAMLY (17) EDUCATONAL BOCA TWO FAMLY (18) (GRADES 112) 0 CAB0 TWO FAMLY (19) DAY CARE FACLTY (8) BOCA SNGLE FAMLY (20) FACTORY CABO SNGLE FAMLY (21) MODERATE HAZARD (9) STORAGE LOW HAZARD (10) MODERATE HAZARD (22) HGH HAZARD (11) LOW HAZARD (23) Exterior (Check those applicable) Walls Steel (1) Concrete (3) Other (5), dentify: Masonry (2) Wood (4) Steel (1) Concrete (3) Other (5), dentify: Masonry (2) Wood (4) Are any structural assemblies fabricated offsite? Street Frontage (Feet) Fmnt Setback (Feet) Rear Setback (Feet) Left Setback (Feet) Right Setback (Feet) Height Above Grade (Feet) New Residential Units () Existing Residential Units () Elevators / Escalator () Est Stalt 1 1 S ber) Bea nooms () F ull Baths (N umber) P artial Baths () Garages () Windows () Fireplaces () Enclosed Parking () Outside Parking () E st Finish / Lot Are!a (Sq feet) Building Area (sq feet) Parking Area (Sq feet) Living Area (Sq feet) Basement Area (Sq feet) Garage Area (Sq feet) OfficelSales (Sq feet) Service (Sq feet) Manufacturing (Sq feet) Building s st value $ 6 ELECTRCAL PERMT APPLCATON Electrical Work n n Total SewiceAMPS of Circuits:2 WlRE 3 WlRE 4 WlRE of Service 0utleh:l OV V POWER DEVCES OUTPUTLOAD POWER DEVCES OUTPUTLOAD Est Start 1 Est Finish / cratitrltial Work st value $ Page 2,,, p~
3 7 PLUMBNG PERMT APPLCATON Plumbing Work NO Enter the of Fixtures Being nstallf TubsShowers Drinking Fountains Shower Stalls Floor Drains Lavatories Water Heaters Roof Openings 1 Bac Toilets Water Softeners Parking Lot Drains Urinals Sewage Ejectors nside Downspouts Sinks Sump Pumps Swimming Pools Total Fixtures Public Water (YN) Public Sewer (Y/N) Water Service Size N, Water Meter Size N, Avg Daily Water Use GPD Utility Service Revisions: Plumbing Work Est Start / Est Finish / Est Value 5 8 MECHANCAL PERMT APPLCATON Mechanical Work NO 1 Enter of New or Replacement Units Forced Air Furnace ncinerator Air Handling Unit Unit Heater 1 Boiler Heat Pump, Gas/Oil Conversion Coil Unit Air Cleaner Space Heater Window AC Unit Kitchen Exhaust Hood Gravity Furnace Split System AC Hazardous Exhaust System Solid Fuel Appliance A/C Compressor Electric Furnace Utility Setvice Revisions: Type of Heating Fuel: (Check One) Gas () Oil (2) [7 Electric (3) [7 Coal (4) [7 Wood (5) [7 Other (6) Mechanical Work Est Start / Est Finish 11 ~ Est Value 5 Permit Type: Description of Work: 9 OTHER REQURED PERMT APPLlCAl Est Start / Est Finish / Value 5 Page 3
4 10 STE PLAN SCALE = 1 nch = FEET Page 4
5 Application Received: 1 1 Application Reviewed: By: Data Entry: 1 By: FLOOD MAP NUMBER & DATE FLOOD ZONE LOWEST FLOOR ELEVATON BASE FLOOD ELEVATON 13 ZONNG PLAN EVALUATON ZONNG DSTRCT MAP NUMBER LOT AREA (From Page 2) LOT COVERAGE (%) LOT AREA PER ROOM ENCROACHMENTS OFF STREET PARKNG SPACES REQURED PROVDED LOADNG SPACE SGNS; NUMBER SZE OF EACH SGN PLANNNG COMMSSON APPROVAL REQURED BOARD OF ZONNG APPEALS APPROVAL REQURED 14 PLAN REVEW RECORD 15 ADDTONAL PERMTS REQURED Page 5
6 ppp ~ 16 PROJECT DOCUMENTS (DRAWNGS & CALCULATONS) TYPE DRAWNGSREPORT SUBMTTED SGNED AND SEALED DATE REVSON DATE Site Plan 7 17 Soil Report Architectural Drawings Structural Drawings Mechanical Drawings 17 '0 Electrical Drawings Job Specifications Structural Connect Drwngs Structural Calculations 17 Special nspection Data 'd Sprinkler Drawings Sprinkler Calculations OTHER DEPARTMENT APPROVALS Fire Public Works Zoning Planning Environmental Management Signature Healtl i and Sanit; ation Water Architectural Review Signature 18 VALDATON Building Permit?ctrical Permit lmbing Permit Mechanical Permit Permitllnsp Fee Permitllnsp Fee Penitlln~p Fee Penitilnsp Fee Permitllnsp Fee Permitllnsp Fee Plan Review Fee (From Part 14) Certificate of Occupancy Fee Other Fee TOTAL FEES Prepared By: Approved By: Title ~ ~ ~ Paae 6 ~ ~ p~ ~
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