Form Amsa-App2 - Mechanical Permit Application
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1
2Leroy Township
Area Metropolitan Services Agency
Newton Township
8156 Four Mile Rd
7988 G. Drive S.
East Leroy, MI 49051
Ceresco, MI 49033
Please make your check payable to the appropriate jurisdiction and send.
616 979-9421
616 979-3212
Emmett Charter Township
City of Battle Creek
Pennfield Charter Township
Bedford Charter Township
City of Springfield
620 Cliff Street
P.O. Box 1717
20260 N.E.Capital Avenue
115 South Uldriks Drive
601 Avenue A
Battle Creek, MI 49017
Battle Creek, MI 49016
Battle Creek, MI 49017
Battle Creek, MI 49017
Springfield, MI 49015
616 968-0335
616 966-3382
616 968-8549
616 965-9096
616 965-2354
MECHANICAL PERMIT APPLICATION
Residential _ _ _ _ _ _ Commercial _ _ _ _ _ _ Industrial _ _ _ _ _ _
Application Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
SECTION I.
Job Location
Name of Owner or Agent
Street Address of Job Location
SECTION II.
Contractor Information (Application MUST be signed)
Contractor Name
License Number
Expiration Date
Address (Street No. & Name)
Government Licensed Under
City
State
Zip Code
(
)
(
)
Telephone Number
Alternate Phone No.
Federal Employer ID Number
Workers Compensation Insurance Carrier
MESC Employer Number
SECTION III.
Homeowner Information (Application MUST be signed)
Homeowner Name
Address (Street No. & Name)
(
)
City
State
Zip Code
Telephone Number
SECTION IV.
Type of Job
Has a building permit been obtained for this project? ______
Single Family: New _ _ _ _ _ _
Remodel _ _ _ _ _ _
Commercial: New _ _ _ _ _ _
Remodel _ _ _ _ _ _
Special Inspection _ _ _ _ _ _
Mobile Home _ _ _ _ _ _
Modular Home _ _ _ _ _ _
SECTION V.
Homeowner Affidavit
I hereby certify the work described on this permit application shall be installed by myself in my own home in which I am
living or about to occupy. All work shall be installed in accordance with the State Construction Code and shall not be
enclosed, covered up or put into operation until it has been inspected and approved by the Inspector. I will cooperate with
the Inspector and assume the responsibility to arrange for necessary inspections.
Signature of Homeowner
SECTION VI.
Application Signature of Homeowner/License
Section 23a of the State Construction Act of 1972, Act No. 230 of the Public Acts of 1972, being Section 125.1523a of the
Michigan Compiled Laws, prohibits a person from conspiring to circumvent the licensing requirements of this state relating
to persons who are to perform work on residential building or a residential structure. Violators of Section 23a are subject
to civil fines.
Signature of Homeowner or Licensee
AMSA-APP2 8/96
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Parent category: Business