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PERMIT APPLICATION - Fayette County Government

PERMIT APPLICATION - Fayette County Government

Fayette

Fayette County Permits & Inspections Department 140 Stonewall Avenue West · Suite 201 · Fayetteville, GA 30214 Phone: 770-305-5403 Fax 770-305-5258 Web: http://www.fayettecountyga.gov/bldg_permits/infobldg.asp AFFIDAVIT FOR DEPARTMENTAL USE ONLY PERMIT NO.: RECEIVED BY / DATE: PAGE 1 of 1 REVISED: 11/16/07 AFFIDAVITS THAT ARE INCOMPLETE, ILLEGIBLE OR SUBMITTED IN ERASABLE MEDIA WILL NOT BE ACCEPTED. TYPE OR PRINT CLEARLY USING PERMANENT BLUE OR BLACK INK. 1. DISCIPLINE TYPE (CHECK ALL THAT APPLY): ELECTRICAL MECHANICAL FUEL GAS PLUMBING 2. SITE INFORMATION: ADDRESS: CITY: ZIP CODE: 3. PERMIT NO.: 4. OWNER’S AND GENERAL CONTRACTOR’S NAME: OWNER’S NAME: GENERAL CONTRACTOR’S NAME: 5. CONTRACTOR’S INFORMATION: NAME: TITLE (CONTRACTOR, QUALIFIED AGENT, ETC.): BUSINESS NAME: BUSINESS LIC. NO.: GEORGIA STATE LIC. NO.: GEORGIA STATE LIC. TYPE: GEORGIA STATE LIC. EXPIRATION DATE: ADDRESS: CITY: STATE: ZIP CODE: DAY PHONE NO.: CELL NO.: THE UNDERSIGNED CERTIFIES THAT ALL WORK ASSOCIATED WITH THE SITE INFORMATION AND PERMIT NUMBER INDICATED ABOVE IN SECTIONS 2 AND 3 RESPECTIVELY FOR THE DISCIPLINE(S) INDICATED ABOVE IN SECTION 1 WILL BE PERFORMED BY THE APPLICANT. ANY CHANGE IN STATUS OF THE DESIGNATED CONTRACTOR MUST BE SUBMITTED IN WRITING TO THE FAYETTE COUNTY PERMITS & INSPECTIONS DEPARTMENT. APPLICANT’S / CONTRACTOR’S SIGNATURE DATE (MUST BE SIGNED IN THE PRESENCE OF A NOTARY) PRINT NAME TITLE (CONTRACTOR, QUALIFIED AGENT, ETC.) Sworn to before me and subscribed in my presence this day of , 20 ___ Notary

Fayette County Permits & Inspections Department 140 Stonewall Avenue West · Suite 201 · Fayetteville, GA 30214 Phone: 770-305-5403 Fax 770-305-5258 Web: http://www.fayettecountyga.gov/bldg_permits/infobldg.asp AFFIDAVIT FOR DEPARTMENTAL USE ONLY PERMIT NO.: RECEIVED BY / DATE: PAGE 1 of 1 REVISED: 11/16/07 AFFIDAVITS THAT ARE INCOMPLETE, ILLEGIBLE OR SUBMITTED IN ERASABLE MEDIA WILL NOT BE ACCEPTED. TYPE OR PRINT CLEARLY USING PERMANENT BLUE OR BLACK INK. 1. DISCIPLINE TYPE (CHECK ALL THAT APPLY): ELECTRICAL MECHANICAL FUEL GAS PLUMBING 2. SITE INFORMATION: ADDRESS: CITY: ZIP CODE: 3. PERMIT NO.: 4. OWNER’S AND GENERAL CONTRACTOR’S NAME: OWNER’S NAME: GENERAL CONTRACTOR’S NAME: 5. CONTRACTOR’S INFORMATION: NAME: TITLE (CONTRACTOR, QUALIFIED AGENT, ETC.): BUSINESS NAME: BUSINESS LIC. NO.: GEORGIA STATE LIC. NO.: GEORGIA STATE LIC. TYPE: GEORGIA STATE LIC. EXPIRATION DATE: ADDRESS: CITY: STATE: ZIP CODE: DAY PHONE NO.: CELL NO.: THE UNDERSIGNED CERTIFIES THAT ALL WORK ASSOCIATED WITH THE SITE INFORMATION AND PERMIT NUMBER INDICATED ABOVE IN SECTIONS 2 AND 3 RESPECTIVELY FOR THE DISCIPLINE(S) INDICATED ABOVE IN SECTION 1 WILL BE PERFORMED BY THE APPLICANT. ANY CHANGE IN STATUS OF THE DESIGNATED CONTRACTOR MUST BE SUBMITTED IN WRITING TO THE FAYETTE COUNTY PERMITS & INSPECTIONS DEPARTMENT. APPLICANT’S / CONTRACTOR’S SIGNATURE DATE (MUST BE SIGNED IN THE PRESENCE OF A NOTARY) PRINT NAME TITLE (CONTRACTOR, QUALIFIED AGENT, ETC.) Sworn to before me and subscribed in my presence this day of , 20 ___ Notary

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