Site Address_________________________________________________________________________________

Is Property Owned by Applicant: Yes_____ No_____

Park Name (if applicable)__________________________________________________ Lot No._____________

Last Name_____________________________________________________ First______________________

Mailing Address______________________________________________________________________________

City___________________ State_____ Zip__________ Phone________________ Cell________________

(If not in mobile home park)

Size and Description of Property__________________________________________________________________

Home setback from property lines: ________ ________ ________ ________

front rear left side right side

*List other structures on property_________________________________________________________________

Dimensions of Home ______________________________________ Date Purchased_____________________

Electrical Contractor_________________________________________________ CE_________________ Master Electrician___________________________________________________ ME_________________

Power Company_______________________ Health Dept. Release #____________ B-1 Seal: Yes___ No___

Certified Installer_________________________________________ Date Installed______________________

I hereby certify that I am the owner of record of the named property, or that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized agent and I agree to conform to all applicable laws of this jurisdiction. In addition, if a permit for work described in this application is issued, I certify that the code official or the code official’s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. I further testify that the above information is true and accurate.

Departmental Approvals: Zoning_______________________________ Date________________­­_