UCC Form F100-1 "Construction Permit Application" - New Jersey

What Is UCC Form F100-1?

This is a legal form that was released by the New Jersey Department of Community Affairs - Division of Codes and Standards - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2008;
  • The latest edition provided by the New Jersey Department of Community Affairs - Division of Codes and Standards;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of UCC Form F100-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Community Affairs - Division of Codes and Standards.

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BLOCK _____________ LOT ______________ QUALIFICATION CODE _______________
ADDRESS (SITE) _________________________________
PERMIT NO. ______________________
V. FEE SUMMARY (for office use only)
Update
Update
1 2 3 4 5
CONSTRUCTION PERMIT
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1. Building
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
2. Electrical
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
APPLICATION
3. Plumbing
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
4. Fire Protection
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
5.
Elevator Devices
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Applicant Completes: Sections I, II, III (optional), IV, VI, and VII
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
6. Subtotal
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
I. IDENTIFICATION
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
7. Less 20% for State Plan Review
$
1.
Proposed Work Site at:
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
8. Subtotal
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
2.
Name of Owner in Fee:
9. State Permit Surcharge Fee
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
$
10. Subtotal
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
e-mail
Tel.
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
11. Cert. of Occupancy
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Address
12. Other
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
street
municipality
zip code
13. TOTAL
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Ownership in Fee:
Public
Private
3.
4.
Principal Contractor:
Tel.
(office use only)
VI. BUILDING/SITE CHARACTERISTICS
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1. Number of Stories
1 2 3
1 2 3
1 2 3
1 2 3
Address
e-mail
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
2. Height of Structure
ft.
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
3. Area — Largest Floor
sq. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
License No. OR, if new home, Builder Reg. No.
Exp. Date
1 2 3
1 2 3
1 2 3
1 2 3
4. New Building Area
sq. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
Home Improvement Contractor Registration No. or Exemption Reason
5. Volume of New Structure
cu. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
6. Max. Live Load
FAX:
Federal Emp. ID No.
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
7. Max. Occupancy Load
1 2 3
1 2 3
1 2 3
1 2 3
5. Architect or Engineer
Contact
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
8. If Industrialized Building: State Approved
1 2 3
1 2 3
1 2 3
1 2 3
HUD
Address
e-mail
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
9. Total Land Area Disturbed
sq. ft.
FAX:
Tel.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
10. Flood Hazard Zone
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
6. Responsible Person in Charge once Work has Begun
1 2 3
1 2 3
1 2 3
1 2 3
11. Base Flood Elevation
ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
Tel.
FAX:
1 2 3
1 2
1 2 3
1 2
1 2
1 2 3
1 2 3
1 2
12. Wetlands
yes
no
1 2 3
1 2
1 2 3
1 2
1 2
1 2 3
1 2 3
1 2
IIa.PROPOSED WORK
VII. DESCRIPTION OF BUILDING USE
Minor Work
New Building
Addition
Demolition
A. RESIDENTIAL (primary use)
1. State Specific Use:
Repair
Alteration
Renovation
Reconstruction
2. Use Group, Proposed:
Select Group
Asbestos Abat. -Subch. 8
Lead Hazard Abatement
Radon Remediation
Annual Permit
3. Change in Use Group, Indicate Present:
(Optional)
Select Group
FOR OFFICE USE ONLY
IIb. SUBCODES
4. No. of dwelling units:
Re-
Plans
Date
Rejection
Approval
Re-
Resubmission Dates
Total Units Income-restricted
Est. Cost
viewer
Rec'd by
Rec'd
Date
Date
viewer
Approval
Rejection
(Check all that apply)
Gained, Sale
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Building
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Gained, Rental
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Lost, Sale
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Electrical
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Lost, Rental
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
B. NON-RESIDENTIAL (primary use)
Plumbing
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1. State Specific Use:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Fire Protection
2. Use Group, Proposed:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Select Group
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Select Group
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
3. Change in Use Group, Indicate Present:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Elevator
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
C. MIXED USE -List secondary use(s):
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
TOTAL COST
$0
D. Construct. Classification:
Present
Proposed
III. PLAN REVIEW (optional)
IV. DOES OR WILL YOUR BUILDING CONTAIN ANY OF THE FOLLOWING?
DO YOU WANT:
1.
Elevators/Escalators/Lifts/
4.
Refrigeration Systems
8.
Smoke Control Systems in Open Wells
12.
Fire Alarm
Dumbwaiters/Moving Walks
5.
Cross-Connections/Backflow Preventers
9.
Underground Storage Tanks
1.
Partial Releases
2.
High Pressure Boilers
6.
Hazardous Uses/Places of Assembly
10.
Swimming Pools, Spas and Hot Tubs
2.
Prototype Processing
3.
Pressure Vessels
7.
Sprinklers/Standpipes
11.
LPGas Tanks
U.C.C. F100-1 (rev. 8/08)
BLOCK _____________ LOT ______________ QUALIFICATION CODE _______________
ADDRESS (SITE) _________________________________
PERMIT NO. ______________________
V. FEE SUMMARY (for office use only)
Update
Update
1 2 3 4 5
CONSTRUCTION PERMIT
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1. Building
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
2. Electrical
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
APPLICATION
3. Plumbing
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
4. Fire Protection
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
5.
Elevator Devices
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Applicant Completes: Sections I, II, III (optional), IV, VI, and VII
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
6. Subtotal
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
I. IDENTIFICATION
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
7. Less 20% for State Plan Review
$
1.
Proposed Work Site at:
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
8. Subtotal
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
2.
Name of Owner in Fee:
9. State Permit Surcharge Fee
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
$
10. Subtotal
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
e-mail
Tel.
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
11. Cert. of Occupancy
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Address
12. Other
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
street
municipality
zip code
13. TOTAL
$
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
Ownership in Fee:
Public
Private
3.
4.
Principal Contractor:
Tel.
(office use only)
VI. BUILDING/SITE CHARACTERISTICS
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1. Number of Stories
1 2 3
1 2 3
1 2 3
1 2 3
Address
e-mail
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
2. Height of Structure
ft.
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
3. Area — Largest Floor
sq. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
License No. OR, if new home, Builder Reg. No.
Exp. Date
1 2 3
1 2 3
1 2 3
1 2 3
4. New Building Area
sq. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
Home Improvement Contractor Registration No. or Exemption Reason
5. Volume of New Structure
cu. ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
6. Max. Live Load
FAX:
Federal Emp. ID No.
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
7. Max. Occupancy Load
1 2 3
1 2 3
1 2 3
1 2 3
5. Architect or Engineer
Contact
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
8. If Industrialized Building: State Approved
1 2 3
1 2 3
1 2 3
1 2 3
HUD
Address
e-mail
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
9. Total Land Area Disturbed
sq. ft.
FAX:
Tel.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
10. Flood Hazard Zone
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
6. Responsible Person in Charge once Work has Begun
1 2 3
1 2 3
1 2 3
1 2 3
11. Base Flood Elevation
ft.
1 2 3
1 2 1 2
1 2 3
1 2 1 2
1 2 1 2
1 2 3
1 2 3
1 2 1 2
1 2 3
1 2 3
1 2 3
1 2 3
Tel.
FAX:
1 2 3
1 2
1 2 3
1 2
1 2
1 2 3
1 2 3
1 2
12. Wetlands
yes
no
1 2 3
1 2
1 2 3
1 2
1 2
1 2 3
1 2 3
1 2
IIa.PROPOSED WORK
VII. DESCRIPTION OF BUILDING USE
Minor Work
New Building
Addition
Demolition
A. RESIDENTIAL (primary use)
1. State Specific Use:
Repair
Alteration
Renovation
Reconstruction
2. Use Group, Proposed:
Select Group
Asbestos Abat. -Subch. 8
Lead Hazard Abatement
Radon Remediation
Annual Permit
3. Change in Use Group, Indicate Present:
(Optional)
Select Group
FOR OFFICE USE ONLY
IIb. SUBCODES
4. No. of dwelling units:
Re-
Plans
Date
Rejection
Approval
Re-
Resubmission Dates
Total Units Income-restricted
Est. Cost
viewer
Rec'd by
Rec'd
Date
Date
viewer
Approval
Rejection
(Check all that apply)
Gained, Sale
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Building
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Gained, Rental
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Lost, Sale
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Electrical
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Lost, Rental
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
B. NON-RESIDENTIAL (primary use)
Plumbing
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1. State Specific Use:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Fire Protection
2. Use Group, Proposed:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Select Group
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Select Group
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
3. Change in Use Group, Indicate Present:
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
Elevator
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
C. MIXED USE -List secondary use(s):
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
TOTAL COST
$0
D. Construct. Classification:
Present
Proposed
III. PLAN REVIEW (optional)
IV. DOES OR WILL YOUR BUILDING CONTAIN ANY OF THE FOLLOWING?
DO YOU WANT:
1.
Elevators/Escalators/Lifts/
4.
Refrigeration Systems
8.
Smoke Control Systems in Open Wells
12.
Fire Alarm
Dumbwaiters/Moving Walks
5.
Cross-Connections/Backflow Preventers
9.
Underground Storage Tanks
1.
Partial Releases
2.
High Pressure Boilers
6.
Hazardous Uses/Places of Assembly
10.
Swimming Pools, Spas and Hot Tubs
2.
Prototype Processing
3.
Pressure Vessels
7.
Sprinklers/Standpipes
11.
LPGas Tanks
U.C.C. F100-1 (rev. 8/08)
CERTIFICATION IN LIEU OF OATH
I.
OWNER SECTION (to be completed if the applicant is the owner in fee)
I hereby certify that I am the owner in fee of the property listed on Page 1.
Mark the following applicable boxes:
A.
( ) I further certify that a new home (private residence) will be constructed on this property for my own use and occu-
pancy. This dwelling is to be occupied by myself and is not to be used for any purpose other than single family
residential use. I attest that all construction, plumbing, or electrical work will be done, in whole or in part, by me or by
subcontractors under my supervision, in accordance with all applicable laws; and, I further acknowledge that said
new home is not covered under the New Home Warranty and Builders Registration Act (N.J.S.A. 46:3B-1 et seq.) and
that such fact shall be disclosed to any person purchasing this property within ten years of the date of issuance of a
certificate of occupancy.
I UNDERSTAND THAT IN MARKING BOX A, I ACKNOWLEDGE THAT I AM ASSUMING RESPONSIBILITY FOR
THE WORK DONE ON SAID PROPERTY, THE CONDITION OF THE PROPERTY PRIOR TO, DURING, AND AFTER
ANY WORK PERFORMED, AND FOR THE PERFORMANCE OF THE SUBCONTRACTORS I HIRE, EMPLOY, OR
OTHERWISE CONTRACT OR WITH WHOM I MAKE AGREEMENTS TO PERFORM WORK. I AM VOLUNTARILY
AND KNOWINGLY ASSUMING THIS RESPONSIBILITY.
B.
( ) I further certify the following as required by the New Jersey Uniform Construction Code, N.J.A.C. 5:23-2.15(f)1.ix:
I personally prepared the plans submitted for: 1) the new home referred to in A.; or, 2) an addition, alteration, renova-
tion, or repair to an existing single family residence owned and occupied by myself and located on the property listed
on Page 1; or, 3) a new structure that will be physically separate from, but that will be deemed part of, an existing
single family residence that is owned and occupied by myself and located on the property listed on Page 1.
C. ( ) I further certify that I will perform or supervise the following work:
C.1. ( ) Building
C.2. ( ) Fire Protection
I further certify that I will perform the following work:
C.3. ( ) Electrical
C.4. ( ) Plumbing
D. ( ) I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of
Taxation and to comply with all New Jersey tax laws.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals, including such certification as the construction official may require, have been given or will be given
prior to pemit issuance.
I understand that if any of the above statements are willfully false, I am subject to punishment.
Signature _____________________________________________________________
Date _______________________
II.
AGENT SECTION (to be completed if the applicant is not the owner in fee)
I hereby certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(d): the proposed work is autho-
rized by the owner in fee; and I have been authorized by the owner in fee to make this application as his agent.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals, including such certification as the construction official may require, have been given or will be given
prior to permit issuance.
I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of Taxation
and to comply with all New Jersey tax laws.
I understand that if any of the above statements are willfully false, I am subject to punishment.
( ) Check if contractor.
Agent Name _________________________________________________________________________________________
Address _____________________________________________________________________________________________
___________________________________________________________________________________________________
Telephone ___________________________
Signature ____________________________________________________________________________________________
III. ( ) LEAD HAZARD ABATEMENT: Include Homeowner or Building Owner Affidavit as per N.J.A.C. 5:23-2.15(b)4.
IV. (
) HOME ELEVATION: Include Home Elevation Contractor Certification as per N.J.S.A. 52:27D-123.16.
U.C.C. F100-2 (rev. 11/2014)
OFFICE DATE RECEIVED: ______________________________
STATE
LOCAL
COUNTY
REGIONAL
VIII. PRIOR
APPROVAL
APPROVAL
APPROVAL
APPROVAL
APPROVALS
COMMENTS
CHECKLIST
Prelimin.
Final
Prelimin.
Final
Prelimin.
Final
Prelimin.
Final
(office use only)
Initial
Date
Initial
Date
Initial
Date
Initial
Date
Zoning Officer
Planning Board
Zoning Board
Sewer Authority
Water Authority
Police Department
Health Department
Soil Conservation
N.J. Department of
Community Affairs
N.J. Department of
Transportation
N.J. Department of
Environmental Protection
Utility Dig No.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
IX. SUBCODES AND SPECIAL REGULATIONS APPLICABLE (office use only—optional)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Name of Code & Edition
Name of Code & Edition
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Building ___________________________________________
Energy ____________________________________________
Other ______________________________________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Electrical ___________________________________________
Barrier Free ________________________________________
__________________________________________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Plumbing __________________________________________
Flood Hazard _______________________________________
__________________________________________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Fire Protection ______________________________________
As Built Elevation Cert. _______________________________
__________________________________________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Mechanical _________________________________________
Other _____________________________________________
__________________________________________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
X. CERTIFICATES ISSUED (office use only)
DATE ISSUED
DATE EXPIRED
DATE REISSUED
DATE EXPIRED
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Temporary Certificate of Occupancy
No. __________
___________________
___________________
__________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Temporary Certificate of Compliance
No. __________
___________________
___________________
__________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Continued Certificate of Occupancy
No. __________
___________________
___________________
__________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Certificate of Compliance
No. __________
___________________
___________________
__________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Certificate of Occupancy
No. __________
___________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Certificate of Approval
No. __________
___________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
Lead Abatement Clearance Certificate
No. __________
___________________
___________________
__________________
___________________
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
U.C.C. F100-3 (rev. 12/07)
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