Minor Permit Application Form Page 2
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1
2MINOR RESIDENTIAL WORKSHEET
(PLEASE TYPE OR PRINT CLEARLY)
ELECTRICAL INFORMATION: Electric Required? Yes______ No______ Existing Service?______ New Service?______ Upgrade Service?______
Limited Use?_______ Disconnect/Reconnect?______ Temporary Underground?_______ Temp Pole: Yes______ No______
Service Size: NEW Amps
Number New/Altered Circuits
______________
Electric Company
. __________________________________
_______________
Volts
Phase 1PH
3PH
OLD Amps
Volts
Phase 1PH
3PH
___________
________
________
______________
__________
_________
_________
MECHANICAL (HVAC): Required? Yes_____ No_____ Duct Work?________ Ventilation?________ General?________ Equipment?________
Type of Equipment______________________________________________ Equipment Location: Inside______ Outside_______
Building Built & Unconditioned Prior to 03/15/79?_________
Roof Top Equipment?___________
Heating System Involved?_________
Type of Heating System
Number of BTU’s
Cooling System Involved?
_________________________________
_________________
___________
Type of Cooling System
Number of Tons
Declared HVAC Costs $
.00
_________________________________
_______________
PLUMBING: Piping?__________ Water Heater?_________ Connection?_________ Backflow Preventer?_________ General? _________
Number of Plumbing Fixtures
Sewer/Septic Connection
Utility Connection
Well Connection
_____________
______________
_____________
_____________
Water Source
Water Company_______________________________________
__________________________________
(Provide Proof of Water Connections)
Sewer Source______________________________ Sewer Company______________________________________
(Provide Proof of Sewer/Septic Connections)
GAS: Type of Gas______________________ Tank Location: Above Ground
/Underground
Number of Tanks_________
________
________
Installation Remote from Structure?
Connection to
Number of Gas Outlets
_________
____________________________________________________
___________
*Metal
*Tile
*Other
ROOF:
(100 sq ft=1) TYPE OF ROOF
: Shingle
______
_______
______
____________________________________________________________
_
Sloped________ Low Sloped______ Combination_____
* These roof types requires a licensed roofer (except for owner/builders)
Minor Repair? Yes____ No_____ Roof Over Existing? Yes____ No____ Number of Layers______ Roof Top Equip? Yes_____ No_____
Structural Change? Yes____ No____ Skylight Replacement? Yes____ No____ Slope of Roof 1___________ Number of Squares Roof 1 ________
Slope of Roof 2
______________ Roof Material 2_________________________________ Number of Squares Roof 2___________
(if applicable)
Slope of Roof 3
______________ Roof Material 3_________________________________
of Squares Roof 3 ___________
(if applicable)
Number
GENERATOR: Fuel Source___________________________ Tank Installation?_________ Number of Gas Connections_________
Tank Location: Above Ground_______ Underground_______ Connection To____________________________________________________________
SOLAR: Heating System? Yes_______ No________ Cooling System? Yes_______ No________ Water Heater? Yes_______ No________
Equipment? Yes_______ No________ Piping? Yes_______ No________ General? Yes_______ No________
Panel Location: Ground Mount_______ Rooftop________ Total Improvement Area >250 Sq Ft? Yes________ No_________
Fire Alarm Required?_______ Fire Alarm Provided?______
Sprinklers Required?_______ Sprinklers Provided?_______
FIRE INFORMATION:
Sprinkler Heads
Declared Fire Alarm Cost $
.00
________
TIED/RELATED PERMIT NUMBERS: Tree___________________________ Use__________________________ Wetland__________________________
Other_______________________________ Well Permit #_________________________________ Septic Permit #________________________________
Directions to property (Physical Location)
_________________________________________________________________________________________
________________________________________________________________________________
GATE CODE___________________________
Bonding Company Name_____________________________________________ Address_______________________________________________________
Mortgage Lender’s Name_____________________________________________ Address_______________________________________________________
Arch’s/Engr’s Name_________________________________________________ Address_______________________________________________________
July 2015
APPROVED BY __________________ (PERMIT OFFICER)
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Parent category: Business