Project Manager: Phone #: Description of work: Architect/Engineer ...
Date of Application:
Please Print legibly and complete all areas.
Check all that apply:
Date Issued: New Structure
Permit #
Remodel of Existing Structure
Multi-family Dwelling 3 or more Units
Project Address:
Tenant Finish
Number of Units___________
Other ____________
Apt/unit #
Project Value: $
Check one:
Subdivision:
Parcel #:
-
Market Value
-
.
Estimate
Phase:
.
Lot #:
.
Sq. ft. of building:_____________ Electrical service size: Amps: ___________ Phase: __________ Volts: _______________
Meters clustered? Number:____________
Description of work:
. .
Owner of Property:
Project Manager:
City:
State:
Zip Code:
Phone #:
.
Cell phone #:
.
Email:
Architect/Engineer: Email:
Phone : (
General Contractor:
Phone : (
Contractor Address:
St. License #
Fax (
)
.
)
)
. -
.
Email:
Electrical Contractor:
Phone : (
Contractor Address:
State License #
Mechanical Contractor (HVAC):
Phone : (
Contractor Address:
State License #
Plumbing Contractor:
Phone : (
Contractor Address:
State License #
)
. -
)
.
-
)
. -
This permit becomes null and void if work or construction is not commenced within 180 days, or if construction is suspended or abandoned for a period of 180 days at any time after work is commenced. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work shall be complied with, whether specified herein or not. The granting of this permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of construction and that I make this statement under penalty of perjury. I agree to abide by the service regulations of Brigham City’s Public Utilities. I further agree to pay Brigham City all incurred charges for utility services rendered as requested herein. In the event that I fail to pay for utility services when due, I agree that utility services may be discontinued and I will pay all costs of collection, including a reasonable attorney’s fee, court costs and collection fees of up to 50% of the balance due. I hereby certify that I have read and examined this application and know the same to be true and correct.
_____________________________________________________ Applicant’s signature
Owner Date:
Contractor
Other, specify
__________________________
24-hour notice is required in order to schedule an inspection.
-Building Department Use OnlyReceipt #
Valuation (market value): $ Building Permit Fee: $ Plan Review fee: $ Prepaid (Plan Review Subtraction) $ Water connection fee:3/4” $ Water connection fee: 1” $ Sewer Connection fee: 4 “ $ Sewer Connection fee: 6” $ Electric Cont. fee: (underground) $ Electric Cont. fee: (overhead) $ Temporary Electric fee: $ State 1% surcharge: $ Deposit: (Refund at building completion) $ ____________________ $ Cut Permit: (work in public right of way) $ Sub total: $ IMPACT FEES (If applicable)
Comments: _____________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ # Buildings
# Stories
Type of Construction: R VALUE
Occupant Load: Occupancy Group:
Walls
Attic
Fire Sprinkled:
Yes
No
Construction Method:
Frame
Concrete
CMU
Steel
ICF
Storm Drain: (Impervious surface) Parks and Recreation: Electrical: Sewer: Water:
$ $ $ $_ $_
________ ________ _ ________ ________ _______
Sub total:
$________________
GRAND TOTAL:
$________________
COMMENTS: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ _________________________________________________
Other
Plan Reviewed by:
Date:
Plans approved by :
Date:
Grandfathered Y
or
N
# of units
Please Print legibly and complete all areas.
Check all that apply:
Date Issued: New Structure
Permit #
Remodel of Existing Structure
Multi-family Dwelling 3 or more Units
Project Address:
Tenant Finish
Number of Units___________
Other ____________
Apt/unit #
Project Value: $
Check one:
Subdivision:
Parcel #:
-
Market Value
-
.
Estimate
Phase:
.
Lot #:
.
Sq. ft. of building:_____________ Electrical service size: Amps: ___________ Phase: __________ Volts: _______________
Meters clustered? Number:____________
Description of work:
. .
Owner of Property:
Project Manager:
City:
State:
Zip Code:
Phone #:
.
Cell phone #:
.
Email:
Architect/Engineer: Email:
Phone : (
General Contractor:
Phone : (
Contractor Address:
St. License #
Fax (
)
.
)
)
. -
.
Email:
Electrical Contractor:
Phone : (
Contractor Address:
State License #
Mechanical Contractor (HVAC):
Phone : (
Contractor Address:
State License #
Plumbing Contractor:
Phone : (
Contractor Address:
State License #
)
. -
)
.
-
)
. -
This permit becomes null and void if work or construction is not commenced within 180 days, or if construction is suspended or abandoned for a period of 180 days at any time after work is commenced. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work shall be complied with, whether specified herein or not. The granting of this permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of construction and that I make this statement under penalty of perjury. I agree to abide by the service regulations of Brigham City’s Public Utilities. I further agree to pay Brigham City all incurred charges for utility services rendered as requested herein. In the event that I fail to pay for utility services when due, I agree that utility services may be discontinued and I will pay all costs of collection, including a reasonable attorney’s fee, court costs and collection fees of up to 50% of the balance due. I hereby certify that I have read and examined this application and know the same to be true and correct.
_____________________________________________________ Applicant’s signature
Owner Date:
Contractor
Other, specify
__________________________
24-hour notice is required in order to schedule an inspection.
-Building Department Use OnlyReceipt #
Valuation (market value): $ Building Permit Fee: $ Plan Review fee: $ Prepaid (Plan Review Subtraction) $ Water connection fee:3/4” $ Water connection fee: 1” $ Sewer Connection fee: 4 “ $ Sewer Connection fee: 6” $ Electric Cont. fee: (underground) $ Electric Cont. fee: (overhead) $ Temporary Electric fee: $ State 1% surcharge: $ Deposit: (Refund at building completion) $ ____________________ $ Cut Permit: (work in public right of way) $ Sub total: $ IMPACT FEES (If applicable)
Comments: _____________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ # Buildings
# Stories
Type of Construction: R VALUE
Occupant Load: Occupancy Group:
Walls
Attic
Fire Sprinkled:
Yes
No
Construction Method:
Frame
Concrete
CMU
Steel
ICF
Storm Drain: (Impervious surface) Parks and Recreation: Electrical: Sewer: Water:
$ $ $ $_ $_
________ ________ _ ________ ________ _______
Sub total:
$________________
GRAND TOTAL:
$________________
COMMENTS: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ _________________________________________________
Other
Plan Reviewed by:
Date:
Plans approved by :
Date:
Grandfathered Y
or
N
# of units
