Fill and Sign the Assignment of Insurance Benefits Appointment as Legal Authorized Representative Form

FOR OFFICE USE ONLY APPLICATION FOR SINGLE FAMILY RESIDENTIAL BUILDING PERMIT STATE OF TENNESSEE Permit #: Receipt #: DEPARTMENT OF COMMERCE & INSURANCE STATE FIRE MARSHAL Date: PERMITTEE FIRST NAME: LAST NAME: 1. DESCRIPTION OF THE WORK TO BE PERFORMED New Construction Single Family Addition of 30 Sq. Ft. or more in interior space Change of Occupancy to Single Family Residential Heated Sq. Ft. of work to be performed: Unheated Sq. Ft. of work to be performed: For additions and changes in occupancy only: Will new construction include plumbing or HVAC? Foundation: Conventional (crawl space with no slab) Basement: Yes Slab and Footing cast separately (for finished living areas only) Yes No Slab and Footing cast monolithically (for finished living areas only) No Number of stories (not including basement) of new construction or addition: 1 2 3 Applicable on 3 story with basement only: I certify the finished surface of the floor above the basement is not more than 6 ft above grade plane, (b) is not more than 6 ft above the finished ground level for more than 50% of the total No Yes building perimeter or (c) is not more than 12 ft above the finished ground level at any point. 2. LOCATION OF CONSTRUCTION Street #: Prefix: Street Name: Suffix: City: County: Is this property within the city limits? Parcel ID #: Ctrl Map: No Yes Grp: ZIP: City, if different from mailing address: Parcel: Example: 089 A 030.22 For information on your Parcel ID #, please visit http://www.assessment.state.tn.us If this property is part of a parent parcel that has not been assigned a Parcel ID #, please use the parent parcel's ID #. LAST NAME: 3. OWNER FIRST NAME: Street #: Prefix: Street Name: Suffix: City: State: Phone: Email: 4. PERMIT FEES Actual Expected Construction Cost: Fee: Plus $100 if slab other than monolith: Mechanical and/or Plumbing: TOTAL: 5. PERMIT DELIVERY Personal Delivery IN-1741 Email Mail 47 ZIP: Homeowner-Applicant Affidavit for Building Permit: Questions - If you answer "No" to any of these questions, you do not legally qualify: 1. I am a record owner of the property on which the work is to be performed and this residential structure is for my own individual use and is not for sale, lease or rent and a homeowner permit has not been obtained by me within the last two (2) years. No Yes 2. I will perform all work for which the building permit was issued, except where otherwise noted, and agree to ensure anyone hired must show proof of license where required by state law ($25,000 or more for materials and labor.) Yes No 3. I am not hiring a construction manager to oversee the project. No Yes 4. I understand that should I cease to act as the ownerbuilder of the project, and hire a contractor to complete the project, this permit will be voided and the contractor will apply for a new permit. Yes No I, [Homeowner Name] CONTRACTOR NAME: Address: City: ZIP: Phone: Email: OR , certify by signing below that I have read the important notices document and understand the requirements and responsibilities that accompany a Homeowner's Permit and that I have truthfully completed this application and that I certify availability of a public sewer or obtainment of a septic permit and all licenses or permits required by state or local law or ordinance. Signature of Property Owner State: 47 Date For online submissions only: By checking this box, I agree to the above statement and allow this to serve as my electronic signature. Contractor License #: Classification: BC BC-A BC-B APPLICANT SIGNATURE I hereby certify that I have completely read the important notices document and truthfully completed this application and that I have complied with the Business licensing and Workers' Compensation laws of the State of Tennessee*, that I am properly licensed pursuant to T. C.A. Title 62, chapter 16 and I certify availability of a public sewer or obtainment of a septic permit and all licenses or permits required by state or local law or ordinance. Signature of contractor/authorized agent For online submissions only: By checking this box, I agree to the above statement and allow this to serve as my electronic signature. * Questions regarding Workers' Compensation should be directed to the Tennessee Department of Labor and Workforce Development at 615-741-2395 or www.tn.gov/labor-wfd/wcomp FOR OFFICE USE ONLY I am an authorized issuing agent and have retained a signed copy of this application in my files. Issuing Agent ID #: by: PIN Voluntary Statistical Information Request: Please check any of the following that apply to this residence: Fire sprinkler system included To Submit This Application Online (Final Step): Important! First Click "Print Form" to print yourself a local copy: After you have your local copy saved, Click Submit to complete the electronic submission: IN-1741 Date Print Form Submit RESIDENTIAL BUILDING PERMIT IMPORTANT NOTICES DEPARTMENT OF COMMERCE & INSURANCE STATE FIRE MARSHAL Please Read: This is a building permit ONLY! This is not: · zoning approval; · grading or fill approval; · determination of floodplain compliance; · septic or sewer permit; or · electrical permit The issuance of a permit shall not be construed to be a permit for, or an approval of, any violation of any state law or regulation or any local ordinance and any such permit shall not be valid. A permit only gives the right to build if you are in compliance with all other state laws and regulations and local ordinances. Inspections. Permittee is solely responsible for scheduling inspections. The following inspections will be required under this: · Footing or monolith slab (schedule a minimum of 1 business day in advance) · Slab other than Monolith (if applicable) (schedule a minimum of 1 business day in advance) · Rough In (schedule a minimum of 3 business days in advance) · Final (schedule a minimum of 3 business days in advance) · Plumbing and mechanical (if applicable) (performed at the same time as Rough In and Final) Cancellations must be called in a minimum of three hours in advance of the scheduled inspection time. Any inspection may be waived if an inspection letter approving the work is signed and submitted by an Architect or Engineer currently registered in the State of Tennessee. Consultation inspections and temporary certificates of occupancy shall also require an additional fee of $100. Re-inspections. In the event more than one rejection is issued during the building inspection process, an additional inspection must be obtained for each subsequent rejection and an additional fee of $100 must be paid. Inspections do not warrant workmanship. Inspections performed by any employee, agent or contractor of the State of Tennessee are performed solely for purposes of enforcement of the applicable building codes on the date of the inspection which may utilize a spot check performance standard, and do not provide comprehensive home inspection services, which are the responsibility of the owner. A Certificate of Occupancy must be issued prior to use. Duplicate Permits. Upon completion of a request form prescribed by the Department, a duplicate original permit may be obtained for a fee of $10 in the event of a loss or destruction thereof. General Contractor or Owner Permit Changes. If during the construction process a property owner decides to hire a contractor, or there is a change of contractor, a new permit must be obtained. Any refund of inspections fees must be requested from the State Fire Marshal's Office. Pursuant T.C.A. § 62-6-103, an owner of property may construct a single residence, once every two (2) years, for their own use, as long as it is not for resale, lease or rent. However, anyone hired by the homeowner would be considered a "prime" contractor or a construction manager, and they would not be exempt from the license requirements, should their portion be in the amount of $25,000 or more. To ensure the contractor is properly licensed with the correct license classification and monetary limit, please check with the Contractor's Board at 1-800-544-7693 or search http://verify.tn.gov Permit Duration. A building permit shall be void if the authorized work is not commenced within 180 days after its issuance. If the work authorized by a permit is commenced and then suspended or abandoned for a period of 180 days a building permit shall be void. Permits expire upon completion of the work and every building permit shall expire 2 years from the date of issue or upon the issuance of the certificate or occupancy, unless: (1) the inspector determines that substantial progress has been made in the work authorized by the permit; and (2) the permit holder is granted an exception after submitting a written request to the Commissioner of Commerce and Insurance, or designee thereof. For frequently asked questions about the state residential building permits, see http://homebuilding.tn.gov. For questions not answered on the website, call 615-741-7170. Call 1-866-283-6191 and select Option 2 to schedule an inspection between the hours of 6:00AM - 4:30PM Central Time. Only permittee may schedule an inspection.