Construction Project Permit Form

CONSTRUCTION PROJECT PERMIT

Permit No.:    Issue Date:

WHEREAS

WHEREAS, Applicant Name: (hereinafter "Applicant") seeks authorization to undertake construction activity at Project Address: .

WHEREAS, the issuing authority has reviewed the application materials and related plans and is prepared to grant a permit subject to the terms, conditions and fees set forth in this instrument.

APPLICANT & CONTRACTOR INFORMATION

CONTRACTOR / LICENSE

PROJECT DETAILS & SCOPE OF WORK

Estimated Construction Cost: $    Proposed Start Date:    Proposed Completion Date:

New Construction    Addition    Renovation    Demolition

Electrical    Plumbing    Mechanical    Other:

INSPECTIONS, SAFETY & INSURANCE

Footings / Foundations    Rough Framing    Electrical    Plumbing

Mechanical    Final Inspection    Other:

Yes    No

PAYMENT TERMS

Permit Fee Amount: $    Payment Due:

Payment Schedule:

Late Fee / Interest for overdue payment: . Fees paid are non-refundable except as required by law.

TERM AND TERMINATION

Permit Term Commences on: and expires on: unless extended in writing by the issuing authority in accordance with applicable code.

The issuing authority may suspend or revoke this permit for failure to comply with permit conditions, applicable building codes, safety or environmental requirements, or for misrepresentation in the application. Applicant may terminate activity by providing written notice to the issuing authority at least days prior to cessation of work.

CONFIDENTIALITY

Project plans and proprietary technical information submitted by Applicant shall be treated as confidential by the issuing authority to the extent permitted by law. Notwithstanding the foregoing, the issuing authority may disclose information as required by statute, court order, or to other governmental entities for permitting, inspection, or public safety purposes. Applicant warrants that any materials marked confidential do not include information required by law to be public.

INDEMNITY, COMPLIANCE & INSPECTION

Applicant shall comply with all applicable building, safety, environmental and zoning laws, and shall indemnify, defend and hold harmless the issuing authority and its officers, employees and agents from any claims, liabilities, losses or expenses arising out of the permitted work except to the extent caused by the gross negligence or willful misconduct of the issuing authority. Applicant shall provide access for inspections at reasonable times and comply with all corrective orders issued by the authority.

GOVERNING LAW & ENTIRE AGREEMENT

Governing Jurisdiction: . This permit and the conditions herein are governed by the laws and regulations of the governing jurisdiction.

Entire Agreement: This permit, together with approved plans and attachments and any written amendments, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior written or oral statements. Any modification must be in writing and signed by the issuing authority.

CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that the information submitted is true and correct, that all work will be performed in accordance with approved plans, applicable codes and permit conditions, and that Applicant has the authority to request this permit. The Applicant acknowledges that work begun without an approved permit may be subject to stop-work orders, penalties, and revocation.

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