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L:\BUILDING DIVISION\Forms\APPs\BLDG-001 RESIDENTIAL BUILDING PERMIT APPLICATION.doc Rev: 10/2006 Page 1 of 3 Community Development Department 595 Silver Lace Blvd., Fernley, NV 89408 [PHONE REDACTED] PERMIT APPLICATIONS, PLANS OR SUPPORTING DOCUMENTATION THAT ARE INCOMPLETE, ILLEGIBLE OR SUBMITTED IN PENCIL OR ERASABLE INK WILL NOT BE ACCEPTED. PLEASE PRINT CLEARLY USING PERMANENT BLUE OR BLACK INK. APPLICANT’S NAME: ROLE: OWNER CONTRACTOR OTHER: COMPANY: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: APPLICANT’S INFO.: PHONE NO.: CELL NO.: FAX NO.: ASSESSOR PARCEL NO. (APN): FLOOD ZONE: YES NO PROJECT ADDRESS: BUILDING OR SUITE NO.: CITY: FERNLEY STATE: NV ZIP CODE: 89408 SUBDIVISION: BLOCK: LOT NO.: PARCEL INFO.: TOTAL LOT AREA: ZONING: SETBACKS – FRONT: SIDES: REAR: / CORNER PARCEL: PROJECT DESCRIPTION: NEW ADDITION REMODEL DEMOLITION OTHER: BUILDING HEIGHT ABOVE GRADE (FT): PROJECT/UNIT TYPE: DETACHED ONE- OR TWO-FAMILY DWELLING TOWNHOUSE ACCESSORY STRUCTURE: NO. OF STORIES: NO. OF UNITS: NO. OF BEDROOMS: NO. OF BATHROOMS: GARAGE SIZE: – CAR VALUATION AMOUNT: $ -OR- CONTRACT AMOUNT (PROVIDE COPY): $ FIRE SPRINKLER: YES NO ARE AREAS OVER 3600 SQ. FT., SEPARATED BY FIRE WALLS? YES NO NOT APPLICABLE FLOOR AREAS (SQ. FT.): LIVING SPACE: DECKS: PORCHES: BASEMENT/STORAGE: GARAGE: OTHER: TOTAL STRUCTURE AREA: UTILITY INFORMATION: CITY SEWER ( NEW EXISTING) CITY WATER ( NEW EXISTING) NATURAL GAS ( NEW EXISTING) LPG/PROPANE GAS ( NEW EXISTING) – TANK SIZE: – GALLONS ELECTRICAL SERVICE ( OVERHEAD UNDERGROUND) SEPTIC SYSTEM ( NEW – PROVIDE PERCOLATION TEST RESULTS AND SITE PLAN EXISTING – PROVIDE VERIFICATION AND SERVICE LETTER) SEPTIC TANK SIZE: – GALLONS ABSORPTION AREA – NO. OF DISTRIBUTION LINES: LENGTH OF DISTRIBUTION LINES (FT): WELL ( NEW – PROVIDE WELL DRILLER’S LOG AND LAB RESULTS EXISTING – PROVIDE WELL DRILLER’S LOG AND LAB RESULTS) NEW PLANS ATTACHED NO PLANS PLANS ON FILE – CITY OF FERNLEY PLAN NO.: NO. OF PLUMBING FIXTURES: WATER CLOSETS (TOILETS): LAVATORIES: SINKS (KITCHEN / LAUNDRY): PERMIT / PROJECT INFORMATION: BATHTUB: SHOWER: BATH/SHOWER COMBO: FOR BUILDING DIVISION USE ONLY FILING DATE: BY: ISSUED BY: DATE: W/B PUD RCT: $ BUILDING PERMIT NO.: BP PLAN NO.: PERMIT FEE: $ OWNER–BUILDER PERMIT PURSUANT TO NRS 278.573 ( RECEIVED ACKNOWLEDGEMENT FORM) ROAD TAX: $ RCT DISTRICT #1 #2 RECEIVED WATER – SEWER RECEIPT SCHOOL TAX: $ ZONING REVIEWED BY: DATE: FIRE SPRINKLER SYSTEM REQUIRED BY (IF YES, APPROVAL MUST ACCOMPANY APPLICATION): YES NO DEPOSIT RECEIVED: $ PLANS REVIEWED BY: STARTED: COMPLETED: TOTAL BALANCE DUE: $ ---PAGE BREAK--- L:\BUILDING DIVISION\Forms\APPs\BLDG-001 RESIDENTIAL BUILDING PERMIT APPLICATION.doc Rev: 10/2006 Page 2 of 3 FOR BUILDING DIVISION USE ONLY BUILDING PERMIT NO.: BP OWNER’S NAME: COMPANY: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: OWNER’S INFO.: PHONE NO.: CELL NO.: FAX NO.: ARCHITECT: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: PHONE NO.: CELL NO.: FAX NO.: ENGINEER OF RECORD: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: DESIGN PROFESSIONAL’S INFO.: PHONE NO.: CELL NO.: FAX NO.: BUILDING/GENERAL CONTRACTOR: CONTACT’S NAME: CITY OF FERNLEY BUSINESS LIC. NO.: NV CONTRACTOR LIC. NO.: CLASS: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: PHONE NO.: CELL NO.: FAX NO.: ELECTRICAL CONTRACTOR: CONTACT’S NAME: CITY OF FERNLEY BUSINESS LIC. NO.: NV CONTRACTOR LIC. NO.: CLASS: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: PHONE NO.: CELL NO.: FAX NO.: MECHANICAL CONTRACTOR: CONTACT’S NAME: CITY OF FERNLEY BUSINESS LIC. NO.: NV CONTRACTOR LIC. NO.: CLASS: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: PHONE NO.: CELL NO.: FAX NO.: PLUMBING CONTRACTOR: CONTACT’S NAME: CITY OF FERNLEY BUSINESS LIC. NO.: NV CONTRACTOR LIC. NO.: CLASS: ADDRESS: BUILDING OR SUITE NO.: CITY: STATE: ZIP CODE: CONTRACTOR’S INFORMATION: PHONE NO.: CELL NO.: FAX NO.: ---PAGE BREAK--- L:\BUILDING DIVISION\Forms\APPs\BLDG-001 RESIDENTIAL BUILDING PERMIT APPLICATION.doc Rev: 10/2006 Page 3 of 3 FOR BUILDING DIVISION USE ONLY BUILDING PERMIT NO.: BP I understand and agree that the City of Fernley has no obligation to explain every requirement and ordinance to me prior to or during the course of this project. Furthermore, I understand that any and all City or State laws or ordinances are enforceable at any time, with or without prior notification. The issuance of a permit based on plans, specifications and other construction documents shall not prevent the Building Official from thereafter requiring the corrections of errors in said plans, specifications and other construction documents, or preventing building operations be carried on there under when in violation of City or State laws or ordinances. The Building Official is authorized to suspend or revoke a permit issued under the provisions of the code wherever the permit is issued in error or on the basis of incorrect, inaccurate or incomplete information, or in violation of any ordinance or regulation of the provisions of the code. It shall be the duty of the permit holder or their agent to notify the Building Official that permitted work is ready for an inspection. Requesting an inspection for work that is incomplete, in progress or not ready may result in a reinspection fee. It shall be the duty of the person requesting any inspections required by the code to provide access to and means for inspection of such work. Inspectors will not perform inspections in the presence of any unrestrained animals or in the presence of minors without a parent or legal guardian present. Work shall not be done beyond the point indicated in each successive inspection without first obtaining the approval of the Building Official. Any portion of work shall not be covered or concealed until authorized by the Building Official. The building permit, approved plans and inspection card shall be kept on the site of the work until the completion of the project. The Building Official shall suspend or revoke a certificate of occupancy issued under the provisions of the code wherever the certificate is issued in error, or on the basis of incorrect information supplied, or where it is determined that the building or structure or portion thereof is in violation of any ordinance or regulation or any of the provisions of the code I certify that I have read and understand this application and state that the above information is correct. I agree to comply with all City ordinances and State laws relating to building construction, and hereby authorize representatives of the City of Fernley to enter the above-mentioned property for inspection purposes. I certify that I have a legal right to apply for this residential building permit and to authorize entry. Additionally, I certify that this application is in conformity with all conditions, covenants and restrictions, I have received all approvals required, and that all deed restrictions of record apply to and limit the use of this property. I certify that I am a licensed contractor pursuant to NRS 624. (Initial) I certify that I am an owner-builder pursuant to the provisions of NRS 278.573. (Initial) Signature Date Print Name Title (architect, contractor, etc.) Project Address (address numbers and street name only)