Permit Application Form
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1CITY OF CHESAPEAKE
NUMBER ___________________
Department of Development and Permits
PERMIT APPLICATION
DATE ______________, 20_____
NOTE: Permit application and sketch or plan to be prepared in duplicate.
Name: _______________________________________________
Name: ______________________________________
&
&
Address of
Address of
Permittee: ____________________________________________
Property Owners(s):____________________________
(if not Permittee)
Location of
Work:_____________________________________________________________________________________________
___________________________________________________________________________________________________
Description of Work: __________________________________________________________________________________
___________________________________________________________________________________________________
Permission is hereby granted the permittee, insofar as the City of Chesapeake has the right and power to grant same, to
perform the above described work at the location specified and as shown on attached plans or sketch and described thereon.
The work shall be carried out in accordance with Chapter 66 of the Chesapeake City Code, entitled “Streets and Sidewalks,”
the special provisions contained herein, and the provisions given in the supplement to this form entitled “Permit Application –
Standard Provisions.”
Failure to have in his possession a copy of the latter does not relieve the permittee from the
responsibility of having knowledge of and adhering to the requirements described therein.
Said work shall be completed in a manner satisfactory to the Department of Development and Permits within ___________
days from the date of this permit and if not so completed the Department of Development and Permits may, in its discretion,
complete the work at the expense of the applicant. The City of Chesapeake reserves full municipal control over the subject
of this permit.
Receipt is acknowledged of $____________ (inspection $________________, guarantee $________________) which
covers fees for inspection and guarantee for the faithful performance of the work herein referred to. When guarantee is a
surety bond, give the name and address of the bonding company below. A copy of said bond shall be placed on file in the
Department of Development and Permits.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Permittee further agrees to notify the Department of Development and Permits when the work herein referred to begins and
when completed and to maintain said work thereafter in a manner approved.
Signature
Permittee: _____________________________________________
Approved:___________________________________
Signature of
By: ________________________________________
Property Owner: _______________________________________
or Printed Name of Applicant
Title:_______________________________________
Contact
Phone #: ___________________________________________
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