BUILDING PERMIT APPLICATION

City of Elkhart, Building Department	229 S Second St, Elkhart, IN 46516	(574) 294-5471

Please Type or Print Legibly	3.0

*Job Address:	Permit Number (Office Use Only)
*Property Owner:	*Phone:
*Property Owner’s Address:
Contact Email Address:
Building Contractor (If Applicable):	Phone:
*Present Use of Building:	*Proposed Use of Building: Rental
*Occupancy: Occupied Vacant How long?	*Estimated Value of Work: $
# of Dwelling Units:	# of Stories:	Total Square Ft. of Building:	Square Ft. Work Area:
*Class of Work: New Addition Alteration/Repair Move Demolition Tank Fire Suppression
*Description of Work:
Design Professional: (675 IAC 12-6-9)	Phone:
Occupancy Group:	Type of Construction:	Plan Review Number:(Office Use Only)
State Release #:	Fire Sprinklers?: Yes No	# of Sprinkler Heads:
Scope of Design Release: Foundation Architectural Structural Mechanical Plumbing Electrical
Electrical Contractor(If applicable)	Zoning Approval Stamp or Clearance Number (Office Use Only)
Mechanical Contractor(If applicable)
Plumbing Contractor(If applicable)
Fire Sprinkler Contractor(If applicable)
Other(If applicable)
NOTICE SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THESE PERMITS MUST BE SECURED BY THE LICENSED CONTRACTOR. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 365 DAYS, OR IF CONSTRUCTION OR WORK 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 WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A 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. ____________________________________________________________________________ _____________________________________________________________________________ Signature of Owner or Authorized Agent Date Print Name Title
Special Conditions: (office Use Only) Permit Approved By: ________________________________________________________________________ Date: ________________________________

Form CoE1001-4.10/14