Application for Plan Review and Building Permit (Printable)

FAIRFIELD COUNTY

BUILDING DEPARTMENT

138 West Chestnut Street, Lancaster, Ohio 43130
(740) 652-7110 www.co.fairfield.oh.us

FOR DEPARTMENT USE ONLY

Permit App. No.

Date Received

Date Issued

APPLICATION FOR PLAN REVIEW AND BUILDING PERMIT

Page 1 application fields
SITE ADDRESS:
LOT #: LOT NUMBER	SUBDIVISION/PARCEL No.: SUBDIVISION OR PARCEL NUMBER		TOWNSHIP: TOWNSHIP
LOCATED BETWEEN LOCATED BETWEEN STREET OR ROAD 1 and LOCATED BETWEEN STREET OR ROAD 2
ZONING DISTRICT: ZONING DISTRICT	FLOOD PLAIN ZONE: FLOOD PLAIN ZONE	MAP # MAP NUMBER	DEV. PERMIT No.: DEVELOPMENT PERMIT NUMBER
DESCRIPTION OF PROJECT:
APPLICATION DATE: Application date month / Application date day / Application date year		PROJECT COST: $
ESTIMATED STARTING DATE:		ESTIMATED FINISH DATE:
TYPE OF IMPROVEMENT:	Type of improvement NEW CONSTRUCTION ADDITION ALTERATION REPAIR/REPLACEMENT CHANGE OF USE OCCUPANCY OTHER Other improvement description
APPLICATION FOR:	Application for BUILDING (STRUCTURAL) ELECTRICAL MECHANICAL FIRE SUPPRESSION SIGN FIRE ALARM DEMOLITION FOUNDATION START INDUSTRIALIZED-UNIT OTHER Other application type

COMMERCIAL: OBC USE GROUP: MIXED USE: Mixed use YES NO IF YES; SEPARATED If yes, separated YES NO
Construction type CONSTRUCTION TYPE: IA IB IIA IIB IIIA IIIB IV VA VB
OWNERS NAME:
ADDRESS:
TELEPHONE: OWNER TELEPHONE		MOBILE: OWNER MOBILE
E-MAIL ADDRESS:
CONTRACTOR:
CONTRACTOR REGISTRATION No.:
ADDRESS:
TELEPHONE:		MOBILE:
E-MAIL ADDRESS:
APPLICANT:
ADDRESS:
TELEPHONE:		MOBILE:
E-MAIL ADDRESS
DESIGN PROFESSIONAL:
ARCHITECT / ENGINEER		REGISTRATION No.:
ADDRESS:
TELEPHONE:		MOBILE:
E-MAIL ADDRESS

On mobile: swipe left/right to view the full form without breaking layout.

Page 2 permit detail sections
SQUARE FEET AREA	NEW & ADDITIONS	ALTERATIONS	CHANGE OF USE	OCCUPANCY LOADS
BUILDING AREA
BASEMENT	Basement new & additions	Basement alterations	Basement change of use	Basement occupancy loads
FIRST FLOOR	First floor new & additions	First floor alterations	First floor change of use	First floor occupancy loads
2, 3, 4 FLOORS, ETC.	Upper floors new & additions	Upper floors alterations	Upper floors change of use	Upper floors occupancy loads
TOTAL AREA SQUARE FEET	Total new & additions	Total alterations	Total change of use	Total occupancy loads
BUILDING PERMIT
COMMERCIAL OTHER Other building permit type		BASEMENT TYPE BLOCK POURED WOOD OTHER
# OF ROOMS:
# OF BUILDINGS: Building permit, number of buildings # OF UNITS: Building permit, number of units		# OF FULL BATHS: Building permit, number of full baths # OF 1/2 BATHS: Building permit, number of one half baths
# OF STORIES: Building permit, number of stories HEIGHT IN FEET: Building permit, height in feet		A/C AND ELEVATOR A/C: YES NO ELEVATOR: YES NO
ELECTRICAL PERMIT
ELECTRICAL PERMIT TYPE COMMERCIAL TEMPORARY SERVICE NEW SERVICE ADDITION/ALTERATION REPLACEMENT/REPAIR HOT TUB MOBILE HOME SERVICE OTHER Electrical permit type, other description
VOLTAGE:	PHASE:	SERVICE CONDUCTORS:		/ SET # OF SETS:
NUMBER OF METERS:		NUMBER OF MAIN DISCONNECTS:
NUMBER OF FIXTURES, SWITCHES, OUTLETS, ETC.:		NUMBER OF SUB PANELS, DISCONNECTS, ETC.:
FIRE ALARM
FIRE ALARM SYSTEM YES NO		NO. OF DEVICES:
FIRE ALARM TYPE LOCAL CENTRAL STATION REMOTE STATION PROPRIETARY OTHER Fire alarm type, other description
FIRE SUPPRESSION
FIRE SUPPRESSION OPTIONS SPRINKLERS HOOD SUPPRESSION LIMITED AREA
TYPE OF SYSTEM: WET DRY ANTI-FREEZE CHEMICAL OTHER Other fire suppression system
NO. OF HEADS:		NO. OF STANDPIPES:		NO. OF RISERS:
HVAC PERMIT
Describe Heating System: BRAND: MODEL:		# OF UNITS: OUTPUT (BTU/HR): TONS: FUEL TYPE: # OF OUTLETS:
Describe Cooling System: BRAND: MODEL:		FORCED AIR RADIANT GRAVITY INFRARED HEAT PUMP BOILER/STEAM CONDENSING UNIT COOLING TOWER EVAPORATION COOLER
TYPE: COMMERCIAL NEW ADDITION ALTERATION REPLACEMENT/REPAIR		FIREPLACE TYPE: MASONRY MANUFACTURERED INSERT STOVE SOLID FUEL GAS LOGS

On mobile: swipe left/right.

Page 3 certification and applicant statement sections
DEMOLITION PERMIT
STRUCTURE(S) TO BE: MOVED DEMOLISHED OTHER Other demolition structure description MOST RECENT USE OF BUILDING(S):	TOTAL SQUARE FOOTAGE OF BUILDING(S): PROPOSED USE OF SITE FOLLOWING DEMOLITION:
SIGN PERMIT
SIGN HEIGHT: FEET Sign height inches INCHES: SIGN FACE AREA: Sign face height HT X Sign face width WD = Sign face square feet SQ. FT.
IS THERE A COMPREHENSIVE SIGN PLAN FOR THIS SITE? YES NO
TYPE: WALL GROUND PROJECTION AWNING CANOPY SUBDIVISION FACE REPLACEMENT OTHER Other sign permit type
CHARACTERISTICS: DOUBLE FACED PERMANENT TEMPORARY ILLUMINATED NON-ILLUMINATED ON-PREMISE OFF-PREMISE OTHER Other sign characteristic
SWIMMING POOL PERMIT
SWIMMING POOL TYPE: ABOVE GROUND IN-GROUND OUTDOOR INDOOR	SIZE: FEET X Pool size second value FEET OR DIA.: Pool diameter feet FEET TOTAL SQUARE FOOTAGE :
DOES POOL HAVE A DECK/ WALKWAY/ APRON AROUND IT? YES NO	HOW IS POOL PROTECTED? 5-FT. MINIMUM BARRIER REQUIRED. FENCED YARD BUILT-IN GUARDRAIL
CERTIFICATION
Certification summary and applicant acknowledgment section.
ALL PERMITS SHALL EXPIRE ONE YEAR FROM THE DATE OF ISSUE. A ONE TIME RENEWAL SHALL BE PERMITTED IF THE ORIGINAL PERMIT HAS NOT EXPIRED. RENEWED PERMITS SHALL EXPIRE ONE YEAR FROM THE RENEWAL DATE. I FULLY UNDERSTAND THAT NO EXCAVATION, CONSTRUCTION, OR STRUCTURAL ALTERATION, ELECTRICAL OR MECHANICAL INSTALLATION OR ALTERATION OF ANY BUILDING, STRUCTURE, SIGN, OR PART THEREOF AND NO USE OF THE ABOVE SHALL BE UNDERTAKEN OR PERFORMED UNTIL THE PERMIT APPLIED FOR HEREIN HAS BEEN APPROVED AND ISSUED BY THE FAIRFIELD COUNTY BUILDING DEPARTMENT. I hereby certify that I am the owner of the named property, or that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application as his/her authorized agent and I agree to conform to all applicable laws of the jurisdiction. In addition, if a permit for work described in this application is issued, I certify that the code official or the code official’s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. I HEREBY ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE LISTED INSTRUCTIONS.
SIGNATURE OF APPLICANT:	DATE: PRINT NAME:
HOLD / DATE: Hold date REASON:	INCOMPLETE COMPLETE APPROVED DISAPPROVED BUILDING OFFICIAL: PLANS EXAMINER:
General/Structural Electrical HVAC/Refrigeration Sprinkler/Fire Suppression Fire Alarm - # Devices Fire Alarm number of devices Minor Work Minor work description Plan Review Fee	Final Certificate (due and payable with building permit) Occupancy or Change of Use Demolition Foundation Start Temporary Electric Service Variance from a Building Code Section Miscellaneous Charges-explain Miscellaneous charges explain

On mobile: swipe left/right.