Fill and Sign the Combined Insurance Form

JOB NO: (OFFICE USE ONLY) DATE: PERMIT NO: (OFFICE USE ONLY) APPLICATION TYPE PERMIT CO OTHER EXPRESS HEALTH REVIEW (Restaurants/Food Service) BUILDING INSPECTION APPLICATION STREET ADDRESS OF PROPOSED PROJECT SUITE/BLDG/FLOOR NO OWNER/TENANT USE OF PROPERTY CITY ADDRESS DBA (IF APPLICABLE) STATE ZIP CODE E-MAIL ADDRESS APPLICANT CONTR NO COMPANY NAME ADDRESS CITY STATE ZIP CODE DESCRIPTION OF PROPOSED PROJECT PHONE NO FAX NO ALL FOOD SERVICE ESTABLISHMENTS REQUIRE A GREASE INTERCEPTOR INSTALLED ONSITE. CHECK BOX IF THERE IS ONE LOCATED ON THE PROPERTY. NEW CONST VALUATION ($) CONST AREA (sq ft) NEW CONST REMODEL LEASE TOTAL AREA REMODEL TOTAL VALUATION PLEASE INDICATE ALL TYPES OF WORK THAT WILL BE PART OF THIS PROJECT BY CHECKING THE APPROPRIATE BOX AND PROVIDE CONTRACTOR/SUBCONTRACTOR INFORMATION ON THE BACK OF THIS FORM. NOTE: AN AFFIDAVIT IS REQUIRED FOR THE SALE OR SERVING OF ALCOHOL. BUILDING PLUMBING FENCE DRIVE APPROACH BACKFLOW BARRICADE ELECTRICAL FIRE SPRKLR SIGN SWIMMING POOL CUSTOMER SVC GREEN BUILDING/LEED MECHANICAL FIRE ALARM LANDSCAPE LAWN SPRINKLER FLAMMABLE LIQUID OTHER: WILL ALCOHOL BE SOLD/SERVED? YES NO PERSONAL SERVICE LICENSE REQUIRED FOR THE PROPOSED USE? YES NO WILL THERE BE A DANCE FLOOR? YES NO ARE POTENTIALLY HAZARDOUS FOODS/OPEN FOODS BEING SOLD? YES NO I HAVE CAREFULLY READ THE COMPLETED APPLICATION AND KNOW THE SAME IS TRUE AND CORRECT AND HEREBY AGREE THAT APPLICANT SIGNATURE IF A PERMIT IS ISSUED ALL PROVISIONS OF THE CITY ORDINANCES AND STATE LAWS WILL BE COMPLIED WITH WHETHER HEREIN SPECIFIED OR NOT. I AM THE OWNER OF THE PROPERTY OR THE DULY AUTHORIZED AGENT. PERMISSION IS HEREBY GRANTED TO ENTER PREMISES AND MAKE ALL INSPECTIONS. FOR OFFICE USE ONLY ZONING BUILDING MISCELLANEOUS LAND USE TYPE OF WORK BASE ZONING PD CONSTRUCTION TYPE OCCUPANCY ACTIVITY OWN LOT BLOCK REQUIRED PARKING PROPOSED PARKING SPRINKLER OCCUPANT LOAD FLOOD PLAIN AIRPORT LOT AREA BDA SUP RAR STORIES DWELLING UNITS SPECIAL INSPECTIONS HISTORICAL DIR EARLY RELEASE DEED RESTRICTION PARKING AGREEMENT NUMBER BEDROOMS NUMBER BATHROOMS DRY LL ROUTE TO REVIEWER DATE APPLICATION REMARKS FEE CALCULATIONS ($) PRE-SCREEN PERMIT FEE ZONING SURCHARGE BUILDING ELECTRICAL PLUMBING/MECHANICAL GREEN BUILDING HEALTH HISTORICAL/CONS DIST PLAN REVIEW FEE PREQUALIFICATION REVIEW FEE EXPRESS PLAN REVIEW HOURLY FEE TOTAL HEALTH PERMIT FEE PUBLIC WORKS OTHER FEES WATER OTHER FEES FIRE LANDSCAPING AVIATION OTHER:______________ OTHER FEES TOTAL FEES $ SUSTAINABLE DEVELOPMENT AND CONSTRUCTION DEPARTMENT  BUILDING INSPECTION DIVISION OAK CLIFF MUNICIPAL CENTER, 320 E. JEFFERSON BLVD., ROOM 118, DALLAS, TX 75203  TEL. NO. (214) 948-4480 REV 12-21-2012 CONTRACTORS GENERAL CONTRACTOR NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE NAME CONTR NO COMPANY NAME ADDRESS CITY STATE ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO ZIP CODE PHONE NO FAX NO DESCRIPTION OF WORK ELECTRICAL CONTRACTOR DESCRIPTION OF WORK MECHANICAL CONTRACTOR DESCRIPTION OF WORK PLUMBING CONTRACTOR DESCRIPTION OF WORK OTHER CONTRACTOR DESCRIPTION OF WORK OTHER CONTRACTOR DESCRIPTION OF WORK OTHER CONTRACTOR DESCRIPTION OF WORK CONTRACTOR COMMENTS SUSTAINABLE DEVELOPMENT AND CONSTRUCTION DEPARTMENT  BUILDING INSPECTION DIVISION OAK CLIFF MUNICIPAL CENTER, 320 E. JEFFERSON BLVD., ROOM 118, DALLAS, TX 75203  TEL. NO. (214) 948-4480 REV 12-21-2012 Notice and Agreement on Time for Issuance of Building Permit Applicant’s Name: ____________________________________ Date: _______________ Permit Address: __________________________________________________________ Permit Application Number: ________________________________________________ Description of Permit: _____________________________________________________ Plans Examiner: __________________________________________________________ As required by Texas Local Government Code Section 214.904, the City of Dallas will grant or deny your permit application to erect or improve a building or other structure no later than the 45th day after the application is submitted. Denial of a permit application due to time constraints may be avoided by agreeing to allow the City the following additional time to review the application: “I hereby agree to deadline of 45 days after the date the development code review is completed or 14 days after the date I provide the plans examiner: (1) any required corrections, (2) any additional required documents, (3) a copy of the early release (if applicable), and (4) a copy of the final filed plat (if applicable); whichever results in a longer time period” I Agree: □ I do not Agree: □ Applicant’s Signature: _______________________________________________ Applicant’s Title: ___________________________________________________ Name of Entity: ____________________________________________________ If the permit application is granted within these deadlines, the City will retain all fees. If the permit application is denied within these deadlines, the City will retain all plan review fees and 20 percent of the permit fee. If the permit application is not granted or denied within the agreed additional time of review, the City will refund any fees associated with the permit application. SUSTAINABLE DEVELOPMENT AND CONSTRUCTION DEPARTMENT  BUILDING INSPECTION DIVISION OAK CLIFF MUNICIPAL CENTER, 320 E. JEFFERSON BLVD., ROOM 118, DALLAS, TX 75203  TEL. NO. (214) 948-4480 REV 12-21-2012