Owner _____________________________________________________________________________________

Address ____________________________________________________________________________________

City _____________________________ State ________ Zip ___________ Tel.# _________________________

Contractor _______________________________ Street Address _____________________________________

City ____________________________ State ______ Zip _____________ Tel.# __________________________

Type of Occupancy

____ Assembly ____ Ambulatory Health Care ____ Business ____ Day-care ___ Mercantile

____ Educational ____ Lodging / Rooming ____ Apartments ____ Hotels / Dorm ____ Storage

____ Res. Board & Care ____ Industrial ____ Health Care ____ One & Two Family Dwelling

____ New Building No. of Stories ____ Sq.ft. per floor ____________ Total Sq.ft. _______________

____ Addition No. of Stories ____ Sq.ft. of Addition _________ Total Sq.ft.________________

Renovations: Description: __________________________________________________________________________________________

__________________________________________________________________________________________

Estimated Cost $ _____________________ Value of Existing Building $ ____________________________

Construction Classification: I II III IV V ___ Protected ___ Unprotected ___ Hr.Rating

Type of Fuel for Heating: ____ Natural Gas ____ Oil ____ LP Gas ____ Electric

Automatic Fire Sprinkler System ____ Yes ____ No

I hereby certify that I have the authority to make the foregoing application, that the application is correct and that the owner of this building and the undersigned agree to comply to the applicable codes and ordinances of this jurisdiction.

Applicant (Please print) _________________________________________ Date ______________________

Check No. ___________ Amount $ ________________ Signature __________________________________