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Building Permit Application Revised 7/7/2016 Page 1 Building Permit Application 101 N. 4th Street / P. O. Box 1030 Douglas, Wyoming 82633 [PHONE REDACTED], Fax: [PHONE REDACTED] Owner’s Name Address City State Zip Code Phone Email Contractor’s Name Address City State Zip Code Phone Sub-Contractors Names & License Numbers: Framing Electrical Roofing Drywall Plumbing Siding Mechanical Concrete Address of Work Being Done: Description of work being done: Zoning District: Flood Zone: Yes No Subdivision: Block: Lot(s): Building Footprint-Sq Ft. Height: Number of Dwelling Units: Proposed use of Building Building Value Plumbing Value Mechanical Value Electrical Value Total Value of Project ICC 108.3: “The applicant for a permit shall provide an estimated value at the time of application. Permit valuations shall include the total value of work, including materials and labor, for which the permit is being issued, such as electrical, gas, mechanical, plumbing equipment, and permanent systems. If, in the opinion of the building official, the valuation is underestimated on the application, the permit shall be denied, unless the applicant can show detailed estimates to meet the approval of the building official. Final building permit valuation shall be set by the building official.” I hereby acknowledge that I have read this application and state that the information contained herein is accurate to the best of my knowledge and agree to comply with all city ordinances and state laws regulating building construction. By signing below, the applicant certifies that they are authorized by the owner to act as their agent. Separate permits may be required for plumbing, mechanical and electrical systems, signs or other work. 24 HOUR NOTICE IS REQUIRED FOR ALL INSPECTIONS Signature Date Application Date: Permit Date Issued: Permit Fee: Approval Date: By: SIGN