Application For Plan Examination And Permit printable pdf download

CITY OF SPRINGFIELD BUILDING & ZONING DEPARTMENT

Application for Plan Examination and Permit for:

Room 304, Municipal Center West

Springfield, Illinois 62701

Building, Demolition, Roof, Sign, Floodplain, Erosion Control, Fence, Parking Lot

PROPERTY INFORMATION:

Ph: (217)789-2171/Fax (217)789-2048

STREET ADDRESS: _____________________________________________ CORNER LOT: YES

NO ZONING: __________________

LEGAL_________________________________________________

LOT WIDTH _____________

LOT DEPTH ____________________

PROPERTY OWNER INFORMATION:

February 20, 2015

NAME: ________________________________________________________ PHONE #: ____________________________________________

STREET ADDRESS:__________________________________________ C,S & ZIP: _______________________________________________

CONTRACTOR INFORMATION:

NAME, ADDRESS, CITY, STATE, ZIP

E-MAIL ADDRESS

PHONE/FAX

GENERAL CONTRACTOR

ARCHITECT/ENGINEER

ELECTRICAL

PLUMBING

MECHANICAL

FIREPLACE

ROOFING

LICENSE #:

IMPROVEMENT TYPE:

USE INFORMATION - PROPOSED USE:

PROJECT

VALUATION: ______________________

____NEW CONSTRUCTION

____DEMOLITION

____EXIST SINGLE FAMILY

____NEW SINGLE FAMILY◄────► SQUARE FOOTAGE: ______________

____ADDITION

____SIDING

____NEW DUPLEX ◄─────────► SQUARE FOOTAGE: ______________

____REMODEL

____SIGN

____NEW CONDO◄──────────► SQUARE FOOTAGE: ______________

____FOUNDATION ONLY

Size ____________

____NEW RES BASEMENT◄────► SQUARE FOOTAGE: ______________

____EROSION CONTROL

Height __________

____NEW RES ADDITION◄─────► SQUARE FOOTAGE: ______________

Less than 1 acre ________

Sq. Ft. __________

REVIEW FEE: _____________________

1 acre and over _________

Illuminated _____

____EXIST: Duplex ___ Condo ____

OCCUPANCY PROHIBITED: _______

____ROOFING

Total Signs _____

____MULTIFAMILY _____ Units

FIRE DAMAGED: __________________

Material ________________

____FENCE

____OTHER______________________

RENEW EXPIRED PERMIT: _______

EXISTING USE:

Number of Squares_________

Height __________

__________________________________ EXTEND ACTIVE PERMIT: ________

Tear Off ________________

Type ___________

Over One _______________

____FLOODPLAIN res

____FLOODPLAIN commercial

CERTIFICATION

• I hereby certify that I am the owner of record of the named property or that the proposed work is authorized by the owner of record and that I have been authorized

by the owner to make this application as his authorized agent and I agree to conform to all applicable federal, state, and local laws. Under penalties of perjury, I hereby

certify that applicant and owner have fully paid all taxes and all the other debts owed to the City of Springfield as of the date of this application. In addition, if a permit

for work described in this application is issued, I certify that the building official or the building official’s authorized representative shall have the authority to enter

areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. Further, I understand and agree to the following:

(1) All permits are subject to any existing easements: (2) The City does not investigate for easements as part of the permit review process: (3) It is the sole responsibility

of the applicant and owner to notify the City of any and all easements in the project area, including those easements held by the City: and (4) Issuance of a permit does

not in any way validate the suitability of the land for the proposed project. Applicant and owner are responsible for soil compaction and mine subsidence research. For

more information, contact the Illinois Department of Natural Resources at 217-782-0588, or visit their website at

• I further certify that I will not commence any development within a floodplain without first obtaining a floodplain development permit from the City of

Springfield. Developments include: New buildings, demolition, reconstruction, substantial improvements to existing buildings, swimming pools, and fences.

See Chapter 150 for a complete description of requirements at , and navigate to the actual Floodplain Regulation ordinance using: “Search

FREE Municipal Code Library”, Illinois, Springfield, Springfield Code of Ordinances, Title XV - LAND USAGE, Chapter 150 FLOODPLAIN REGULATIONS.

SIGNATURE OF APPLICANT

ADDRESS

PHONE NUMBER

**ASBESTOS & LEAD PAINT AWARENESS NOTICE FOR DEMOLITION & RENOVATION PROJECTS**

▼▼▼▼▼

• The Illinois Environmental Protection Agency (IEPA) requires that building owners and contractors notify the IEPA a minimum of ten working days prior to

demolition or renovation activities. Also, the Illinois Department of Public Health (IDPH) requires that building owners and contractors notify IDPH prior to

renovation activities. I hereby certify that I have received and read the United States Environmental Protection Agency (EPA) handout entitled: “Common

Questions on the Asbestos NESHAP”, and that I will file the ten day NOTIFICATION OF DEMOLITION AND RENOVATION with the IEPA if applicable. I also

hereby certify that I have received and read the IDPH handout entitled: “State of Illinois Asbestos Abatement Project Notification Form”, and that I will file the

form with the IDPH if applicable. I understand that the EPA and IDPH handouts may not describe all of the IEPA and IDPH requirements, and I agree to

conform to all applicable federal, state, and local laws. The IEPA may be contacted at (217)785-2011, and the IDPH at (217)782-3517.

• All contractors, and all property owners of rental property, performing work that disturbs painted surfaces in homes and in child care facilities & pre-

schools that were built before 1978 must be U.S. EPA certified, and must follow specific work practices to prevent lead contamination. You must provide the

Renovate Right pamphlet to residents or to the facility operator before work begins. Homeowners living in an owner occupied home performing their own work

are not required, but are encouraged to also follow these regulations. For more information, contact the National Lead Information Center at 1-800-424-LEAD

(5323) or visit I hereby certify I will meet all of the above requirements:

SIGNATURE OF APPLICANT

ADDRESS

DATE

PERMIT #: ___________________

APPROVED

DATE

DENIED

DATE

To reviewer

Review by

ZONING