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APPLICATION FOR SITE PLAN (INFRASTRUCTURE) PERMIT

2. Permit #_________________________
3. Permit Fees $___________________________
4. Date Received______________________
6. 2015 NFPA CODES APPLY
8. Property Owner's Name
   Fee Simple Titleholder’s Name (If other than owner)
9. Phone
10. Address
    Must provide complete address including city, state and zip code
12. Contractor's Name
13. Phone
14. Address
    Must provide complete address including city, state and zip code
16. Email Address:
17. Contractor’s State License
18. PCCLB No.
20. Job Address:
21. Job Description:
23. Legal:
24. Number of Acres:
25. Total job cost
27. Bonding Company
28. Address
    Must provide complete address including city, state and zip code
30. Architect/Engineer’s Name
31. Address
    Must provide complete address including city, state and zip code
33. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
35. FEE: $300.00 per acre or fraction of an acre on Site Infrastructure, Water, Sewer, Reclaimed Water, and Storm Water for Commercial Development.

    I hereby certify that this application, together with plans submitted herewith, is a true representation of all facts concerning the site plan work of the property. It is understood that any deviation from the permit issued will render the permit NULL and VOID and shall be considered as a violation of Article 12 of the Land Development Code.

    AN ELECTRONIC VERSION OF ALL DOCUMENTS BEING SUBMITTED SHALL BE PROVIDED WITH THE PACKET IN .PDF FORMAT IF PLANS ARE LARGER THAN 11 X 17

37. Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction.
    I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, KITCHEN HOODS, FIRE SPRINKLERS, ALARM SYSTEMS, AND SHEDS, ETC.
39. OWNER’S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning.
    OWNER’S ELECTRONIC SUBMISSION STATEMENT: Under penalty of perjury, I declare that all the information contained in this site plan permit application is true and correct.
41. Applications shall be submitted on paper and PDF format, for review and contain all the items listed on application form. In addition, plumbing, electrical, mechanical and environmental plans shall be submitted to secure these permits, when applicable. The permit fee is based on a $300.00 fee per acre or fraction of an acre. Application is valid for 180 days. Permit is extended for 6 months after each successful inspection. Permit expires after 1 year. Permit fee is non-refundable.

    Contractors must maintain, State License, PCCLB License, General Liability and Workman’s Compensation Insurance.

43. Print Name:
44. Select one

    1. Owner
    2. Authorized Agent
    3. Contractor
46. Signature: __________________________________________
47. Date: ____________________
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