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                                                     BUILDING PERMIT APPLICATION
  Print              Clear                                                                                                                   This document has been  
                                                            City of Muskegon                                                              designed to complete online,  
Date                                                               933Terrace St. P.O. Box 536                                                     Permit #
                                                                                                                                        print, SIGN, and mail to the city  
                                                                    Muskegon, MI 49443-0536                                              with all associated fees.  This  
                                                                              (231)724-6758                                                form IS NOT designed to be  
I. JOB LOCATION                                                                                                                              submitted electronically.
Job Address                                                                                   Has a plan review been completed for this project?
                                                                                                     YES               NO               NOT REQUIRED

Name of Owner/Agent                                                                           Owner Telephone


Owner Address                                                              City                                  State                                 Zip Code


II. CONTRACTOR /OWNER INFORMATION
       Contractor       Name                                                                                     License Number                        Expiration Date
       Homeowner

Address(Street & Name)                                                     City                                  State                                 Zip Code


Telephone Number                     Federal employer ID Number (or reason for exemption)                        MESC Employer Number (or reason for exemption)
(       )

Workers Compensation Insurance Carrier (or reason for exemption)                                                 Contractor information registered with the City of
                                                                                                                 Muskegon
                                                                                                                      YES                              NO
III. ARCHITECT OR ENGINEER
Name (Company or Individual)                                                                                                                  License Number

Address                                        City                                           State              Zip code                     Telephone Number


IV. TYPE OF JOB
Class of work (check all that apply)
          NEW BUILDING                                        ADDITION                                       ALTERATION                                        REPAIR

          RESIDENTIAL                                           COMMERCIAL                               INDUSTRIAL                                          OTHER
Description of work


V. FEE  ­ Enter the value of the proposed project.
State the total cost of the improvement , including excavation,                                                                        Permit Fee
building, plumbing, electrical, mechanical and architectural costs                                $

                           Separate permits are required for Plumbing, Mechanical, and Electrical work.
             NO WORK IS TO START PRIOR TO THE ISSUANCE OF BUILDING PERMIT
                         (PROJECTS STARTED WITHOUT A PERMIT MAY BE SUBJECT TO INVESTIGATION FEES)
                                                                                                                  Received By                          Approved




I hereby certify that I have read and examined this application and know the same to be true and correct.  All provisions of laws
and ordinances governing this type of work will be complied with whether specified herein or not.  The granting of this 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.
VI. APPLICANT SIGNATURE
Section 23a of the state construction code act of 1972, 1972 PA 230, MCL 125.1523a, prohibits a person from conspiring to circumvent the licensing
requirements of this state relating to persons who are to perform work on a residential building or a residential structure. Violators of section 23a are
subjected to civil fines."
Signature of licensee or property owner                                                                                                      Date

                                                                                                                                                                          B3/02