) 545-4555 OF FAX (601) 545-4688 TO BE COMPLETED BY APPLICANT DATE: (Sign Permits – see separate application) Shaded Areas are for LDC Staff only Name of Project – Owner: Property Address: Mailing Address: City: ST: Zip: County: Phone: Cellular #: Fax: Structure: New Existing Attached Detached Gross Sq Ft: Net Sq Ft: Number of floors: Parcel #: Zoning Class: Flood Zone: CSR: Panel of 200 Map#: Substantial Improvement Log Posted: Flood Elevation Certificate: Elevations Received: Pre Post Construction Historical Dist: Cert. of Appr: Conforming Use: Code Enforcement Property Zone: Approved by: Type of Construction (please fully describe) Residential: Commercial: Apartments: How many apartment buildings: Units per building: Two (2) complete plans submitted and attached (required for all new commercial and residential construction, also may include renovation/repairs): CHECKLIST Approved Site Plan Field Copy Foundation “PLANS” stamped on permit card Building Inspection copy of plans in files Electrical Lot Size Plumbing Lot Frontage Mechanical Impervious Surfaces Check one: Addition Repair Remodel Roof Grading Other Describe fully: Mobile Home (Registration Number Required): Demolition/Remodel/Renovation: I understand that it is my responsibility to verify if there is Asbestos containing materials. Also, I will abide by the codes of the Mississippi Department of Environmental Quality (DEQ) to properly remove the materials. Please sign: For more information on asbestos removal, call the DEQ at (601) 961-5164. CONTRACTOR INFORMATION VERIFIED BY LDC OFFICE General: ( Owner Compliance Letter) INS BND STE Builder/Remodeler: INS BND STE Electrical: INS BND STE Plumbing &Gas: INS BND STE Mechanical: INS BND STE Specialty Trade: INS BND STE Specify Specialty Type: Performance Bond # if applicable:

Clean-up Person Contact: Company Name: Address: Phone: Signature of responsible party for cleanup/disposal: NOTE: If the city picks up construction debris, a charge of $45.00 per load will be billed to you. Total Job Cost: Permit Cost: Total Appraised Building Value: IF COMMERCIAL PROJECT OVER $10,000, MUST PROVIDE MPC NUMBER: Total Grading Cost: Permit Cost: $15.00 I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS DOCUMENT AND KNOW THE SAME TO BE TRUE AND CORRECT: Permit prepared by: Date: Approved by: Title: Date approved: Permit Number: Cross Reference Permit Number (grading, etc.): Notes/Comments: City of Hattiesburg – Building Permit – Revised 12/30/02 – Form Downloaded From Website

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