DATE*

PROJECT NAME *

DESCRIPTION of PROPOSED WORK:*

OWNER’S INFORMATION:

Name:*

Address:*

Company:*

Telephone: *

Email: *

CONTRACTOR INFORMATION:

Name: *

Address: *

Company: *

Telephone:*

Email:*

PROPERTY INFORMATION:

Address or Parcel ID:*

Permit Fee: $10.00 for all Improvement Location Permits