Permit Application Declarations

PERMIT APPLICATION DECLARATIONS

Recitals

WHEREAS, Applicant Name: seeks authorization to perform the work described in this application and to obtain the permit sought from the Permit Issuing Authority: ; and

WHEREAS, the information provided in this Permit Application Declarations will be relied upon by the Permit Issuing Authority in evaluating compliance with applicable statutes, codes, regulations and local ordinances for property located at Property Address: .

WHEREAS, Applicant represents that the declarations and certifications below are true, complete and accurate to the best of Applicant's knowledge and that Applicant consents to the inspections and conditions set forth herein.

Applicant Information

Individual    Corporation    Limited Liability Company (LLC)    Partnership

Permit Details & Scope of Work

Estimated Commencement Date:    Estimated Completion Date:

Payment Terms & Fees

Permit Fee Amount: $

Late Payment Fee (if any):

Term, Suspension, and Termination

Permit Term Start Date:    Permit Term End Date (if applicable):

Notice Required to Terminate or Suspend Permit: days prior written notice to the Permit Issuing Authority.

Declarations and Certifications

By signing below, Applicant declares, certifies and agrees to the following representations which are material to the issuance of the permit:

1. All information provided in this application and accompanying documents is true, correct and complete to the best of Applicant's knowledge.
2. Applicant has authority to file this application and, where required, has obtained or will obtain any consents of property owners or other parties prior to commencement of work.
3. Applicant will comply with all applicable codes, ordinances, laws, conditions of permit issuance, and shall permit inspections by authorized officials at reasonable times.
4. Applicant acknowledges that false statements, misrepresentations, or omissions may result in permit denial, suspension, revocation, civil penalties or criminal prosecution to the fullest extent permitted by law.

Authorization to Inspect & Access

Applicant hereby authorizes representatives of the Permit Issuing Authority to enter the property identified in this application to inspect, verify, and monitor compliance with the terms of the permit and applicable regulations. Applicant will provide reasonable access and will not obstruct inspections.

Confidentiality

Applicant acknowledges that records submitted in connection with this application may be public records under applicable law. Where submissions contain proprietary or privileged information, Applicant must clearly identify such materials and provide a written statement of the basis for confidentiality; the Permit Issuing Authority will determine disposition pursuant to applicable public records law.

Indemnity

Applicant agrees to indemnify, defend and hold harmless the Permit Issuing Authority, its officers, agents and employees from and against any claims, demands, damages, losses, liabilities, fines, penalties and expenses including reasonable attorney fees arising out of or resulting from Applicant's performance of the work authorized by the permit, except to the extent caused by the authority's negligence or willful misconduct.

Governing Law; Entire Agreement

This Permit Application Declarations and any permit issued pursuant to it will be governed by the laws of the state and local ordinances where the property is located. This document, together with the submitted application materials and permit conditions, constitutes the entire agreement between Applicant and the Permit Issuing Authority with respect to the subject matter and supersedes all prior representations and understandings.

Acknowledgment of False Statements

Applicant acknowledges that knowingly making false statements on this document may constitute a criminal offense under law and may result in criminal prosecution, civil penalties, or both.

Additional Attachments

Declarations — Applicant Certification

I certify under penalty of perjury under the laws of the applicable jurisdiction that the foregoing statements and information contained in this application and attachments are true and correct.

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