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Commercial Building Permit Application

2. Roosevelt City Corporation Building Department
   255 State Street <br> Roosevelt, UT 84066 <br> Phone: 435-722-5001 <br> Fax: 435-722-5000 <br> Email: djohnson@rooseveltcity.com

   255 State Street
   Roosevelt, UT 84066
   Phone: 435-722-5001
   Fax: 435-722-5000
   Email: djohnson@rooseveltcity.com

4. Date Issued

5. Permit Number

7. Duchesne County Assessor's Parcel Number

9. Property Owner

11. Owner of Property Contact Phone Number

12. Owner of Property Email

14. Owner's Mailing Address

16. City

17. State

18. Zip Code

22. Job Site Information

24. Business Name

26. Lot Number

27. Street Address

31. Permit Information

    1. New Commercial Building
    2. 4 Plex Multi Family Dwelling
    3. 3 Plex Multi Family Dwelling
    4. Remodel Existing Building
    5. Addition on Building
    6. Repair Gas line
    7. Repair / Mechanical
    8. Repair / Electrical
    9. Interior Finish

32. Water Meter Size

    1. 3/4 inch
    2. 1 inch
    3. 1 1/2 inch
    4. 2 inch

33. Type of Sewage

    1. Multi Family
    2. Commercial
    3. Small
    4. Large

35. Property has existing Water Meter

    1. Yes
    2. No

36. Property has existing Sewer Service

    1. Yes
    2. No

37. Note: 24 Hour Notice for Inspections

41. All Commercial Buildings or with multiple dwellings units of three (3) or more must have an architect and / or engineer seal

43. Utah Licensed General Contractor's Name

44. Contact Phone Number

46. Contractor Address

47. Utah License Number

48. Email Address

52. Fire Protection Contractor

53. Cell Phone Number

54. Utah License Number

56. Electrical Contractor

57. Cell Phone Number

58. Utah State License Number

60. Mechanical Contractor

61. Cell Phone Number

62. Utah State License Number

64. Plumbing Contractor

65. Cell Phone Number

66. Utah State License Number

70. Square Footage of Excavation

71. Valuation

73. Building Permit Fee

74. Water Impact Fee

75. Electrical Repair Fee

77. Gas Line Change Out Fee

78. Sewer Connection Fee - Commercial

80. Total Fees

81. Date Paid
    Date Paid

82. Paid by

    1. Check
    2. Credit Card
    3. Cash

84. Decisions relative to this application are subject to review by the chief executive officer of the municipal or county entity issuing this building permit and appeal under the International Building Code as adopted by Legislature. This permit becomes null and void if work or construction authorized is not 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 authority regulating construction or performance of construction and that I make this statement under penalty of perjury.

    Decisions relative to this application are subject to review by the chief executive officer of the municipal or county entity issuing this building permit and appeal under the International Building Code as adopted by Legislature. This permit becomes null and void if work or construction authorized is not 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 authority regulating construction or performance of construction and that I make this statement under penalty of perjury.

86. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
88. Electronic Signature of Contractor or Owner if Owner/Builder

89. Date
    Date

91. Building Inspector Signature - Permit Approval

92. Date
    Date

Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit Submit and Print

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