Building Permit Application Form Page 3
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4APPLICANT IS RESPONSIBLE FOR THE PAYING OF ALL FEES AND CHARGES APPLICABLE TO THIS
APPLICATION AND MUST RPOVIDE THE FOLLOWING INFORMATION:
VI. APPLICANT INFORMATION
NAME
TELEPHONE NUMBER
ADDRESS
CITY
STATE
ZIP
FEDERAL ID # OR SOCIAL SECURITY #
I hereby certify 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 we agree to conform to all applicable laws of the State of Michigan. All information
submitted on this application is accurate to the best of my knowledge.
Section 23a of the State Construction Code Act of 1972. Act No. 230 of the Public Acts of 1972, being section 125.1523a of
the Michigan Complied Laws, prohibits a person from conspiring to circumvent the licensing requirements of this State
relating to persons who are to perform work on a residential building or residential structure. Violators of Section 23a are
subject to civil fines
COST OF CONSTRUCTION $_______________
FEE ENCLOSED $ __________________
SIGNATURE OF APPLICANT
APPLICATION DATE
VII. LOCAL GOVERNMENTAL AGENCY TO COMPLETE THIS SECTION
ENVIRONMENTAL CONTROL APPROVALS
REQUIRED
APPROVED
DATE
NUMBER
DATE
A. ZONING
YES NO
B. FIRE DISTRICT
YES NO
C. POLLUTION CONTROL
YES NO
D. NOISE CONTROL
YES NO
E. SOIL EROSION
YES NO
F. FLOOD ZONE
YES NO
G. WATER SUPPLY
YES NO
H. SEPTIC SYSTEM
YES NO
I. VARIANCE GRANTED
YES NO
J. OTHER
YES NO
NOTES AND DATES FOR DEPARTMENT USE
VIII. VALIDATION
BUILDING PERMIT NUMBER
APPROVED BY
ISSUE DATE
SIGNATURE
PERMIT FEE
TITLE
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