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1 Revised 11-19-2008 Gordon County Permit Application Owner Current Address Phone Contractor Address GA. St. License # Phone Address to Property: Directions to Property: Map & Parcel Any other structure/dwellings on property? [ ] Yes [ ] No If so, how many and what kind of structures? Type of Improvement 1 ( ) New Building 2 ( ) Addition 3 ( ) Alteration 4 ( ) Repair Type of Frame 1 ( ) Masonry 2 ( ) Brick Veneer 3 ( ) Wood 4 ( ) Structural steel 5 ( ) Prefab Const. 6 ( ) Modular 7 ( ) Pre-Cast Panels Type of Heat 1 ( ) Gas 2 ( ) Electricity 3 ( ) Wood 4 ( ) Central Heat/Air 5 ( ) None 6 ( ) Gas Lines Proposed Use 1 ( ) Single-Family Dwelling 2 ( ) Multiple Dwelling 3 ( ) Storage Building 4 ( ) Garage 5 ( ) Workshop 6 ( ) Office 7 ( ) Industrial Building 8 ( ) Commercial Building 9 ( ) Religious Organization 10 ( ) Barn 11 ( ) Chicken House 12 ( ) Private Swimming Pool 12 ( ) Public Swimming Pool 14 ( ) Other Dimensions: Number of Stories Total Heated Sq.Ft. Basement (unheated)Sq. Ft. Carport/Garage Sq.Ft. Number of Bedrooms Number of Baths Approx. Cost of New Structure?____________ JOB SITE INFORMATION DESCRIPTION OF BUILDING SIGNATURE THIS BUILDING PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OF ISSUANCE, OR IF WORK OR CONSTRUCTION ACTIVITY IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER PERMIT IS ISSUED. I UNDERSTAND THAT IT SHALL BE UNLAWFUL TO COMMENCE THE EXCAVATION OR FILLING OF ANY LOT FOR CONSTRUCTION OF ANY BUILDING, OR TO COMMENCE CONSTRUCTION OF ANY BUILDING OR TO COMMENCE THE MOVING OR ALTERATION OF ANY BUILDING UNTIL A BUILDING PERMIT FOR SUCH WORK HAS BEEN ISSUED. I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT AND THAT I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO ADHERE TO REQUIRED SETBACKS. OTHER PROVISIONS OF LAWS AND ORDINANCES APPLICABLE TO THIS BUILDING PERMIT WILL BE Filing of this document may create a review of the county's assessment. Reasonable notice is herein provided that an onsite inspection of the subject property by a member of the county appraisal staff may be performed. 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 LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION. SIGNATURE OF APPLICANT: DATE: APPROVAL (official use only) Approved/Rejected Zoned: Permit Fee Building Permit ---PAGE BREAK--- 2 LAND INFORMATION ZONING INFORMATION This section to be filled out if property is not located in a Common Development/ Subdivision Parcel # Map # Any Variance Granted? ( ) Yes ( ) No If Yes Explain FOR OFFICIAL USE ONLY Required Setbacks: Front_______ Other Special Zoning Conditions: Zoning Dept Lot SUBCONTRACTORS Electrical Phone License Holder’s State License Electrical Permit Plumbing Phone License Holder’s State License Plumbing Permit HVAC Phone License Holder’s State License HVAC Permit Gas Line Phone License Holder’s State License Gas Line Permit Type of Sewage System ( ) Public ( ) Septic Tank Permit Type of Water Supply ( ) Public ( ) Well/Cistern Power Company ( ) NGEMC ( ) Georgia Power ( ) Amicola Power ( ) UTILITIES Are there any FEMA Flood Hazard Zones on the property/project site? ( ) Yes ( ) No Is the project disturbing 1.0 Acres or more? ( ) Yes ( ) No (If yes see notes a & b) Will any land disturbance be with in 200 Ft of State Waters? Note e ( ) Yes ( ) No (If yes see note b) Is project part of a Common Development? ( ) Yes ( ) No ( If yes see note c) Is any part of the disturbance/project with in 25’ of warm water or 50’ of trout stream? ( ) Yes ( ) No ( If yes see note a, b & d) Notes: a. NOI must be filled b. Erosion & Sedimentation Control Plans & Local LDA Permit Required c. Secondary Permittee NOI must be filled d. Stream Bank Buffer Variance required from EPD e. For determination of State Waters contact this office (state waters can be any lakes, ponds, creeks, rivers, springs, streams, branches, reservoirs, drainage systems, wells with or without water in or flowing at any time) ---PAGE BREAK--- 3 REQUIRED INFORMATION The following checklist is additional information required to obtain a building permit, please provide listed information and/or documents failure to do so may cause delays in approval of building permit. check [ ] Copy of Recorded Deed [ ] Copy of Recorded Survey [ ] Septic Permit from Environmental Health Department [ ] Fire Permit from Fire Prevention Office (required for commercial building) [ ] Any required soil & erosion plans, permits or variance (if required see Land Information Section) [ ] Site Plan including: [ ] the actual dimensions of the lot to be built upon; [ ] the size of the building to be erected; [ ] the location of existing structures on the lot, if any; [ ] the number of dwelling units the building is designed to accommodate; [ ] the setback lines of buildings on adjoining lots; [ ] other such information as may be essential for determining whether the provisions of the Ordinance are being observed; [ ] other such information as may be required by the Building Official or required by any other County Official and/or Ordinance. FEE DETERMINATION (OFFICIAL USE ONLY) Total Heated Sq. Ft. Basement Sq, Ft. $/Sq. Ft. Const. Cost X from valuation table Carport/Garage Sq, Ft. Total Unheated area Sq, Ft. (e + $/Sq. Ft. Const Cost x from valuation table Cost of Const (heated) (a x b) Cost of Const (unheated) (g x h) Total Cost of Const (heated & unheated) (i + d) for the first plus for each additional thousand or fraction thereof total cost of const. Subtract the first ___thousand = divide by 1000 and round up to the next whole x add Fee