2. Instructions
   Please fill out the entire application. Required fields are marked with an asterisks (*). Incomplete application will not be processed.
4. Job Information
6. Job Site Address*
8. Owner First Name*
9. Owner Last Name*
11. Phone Number*
12. Email Address*
14. Owner Address*
16. Owner Address Cont'd
18. City*
19. State*
20. Zip*
24. Contractor Information
26. Company Name*
28. Contractor First Name*
29. Contractor Last Name*
31. Contractor's Phone Number*
32. Contractor's Email*
34. Contractor Address*
36. Contractor Address Cont'd
38. City*
39. State*
40. Zip*
44. Description and Value of the Work
    Please provide a detailed description and valuation of each kind of project that will be performed at this location and as part of this permit. For example, if you are replacing the roof, indicate the details of that replacement and the value of it. Please include specific information about each part of the overall building project.
46. Description of Work*
47. Valuation*
49. Description of Work
50. Valuation
52. Description of Work
53. Valuation
55. Description of Work
56. Valuation
58. Description of Work
59. Valuation
63. Notices & Signature
65. Notice
    This permit becomes null and void if the work or construction authorized is not commenced within 180 day from the date of issuance; or if the work or construction is suspended or abandoned for a period of 180 days at any time after work is commenced.
67. Acknowledgement*

    I hereby certify that I have read and understand this application and affirm that the information contained within is true and correct to the best of my knowledge. All provisions of laws and ordinances governing this type of work will be complied with and followed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of contstruction.

    1. I have read, understand, and agree to this statement
69. Electronic Signature*

    By clicking this box....

    1. Electronic Signature
70. Date*
    Date
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field