PERMIT INFORMATION®

Developer’s Name: __________________________________________________________________________

Developer’s Contact Name: _______________________________________ Title: _     ____________________

Email: ____________________________________________________________ Phone: __________________

Complete Address: __________________________________________________________________________

Employer ID #: __________________________ Phone: _________________________ Fax: ________________

Property Owner: ____________________________________________________________________________

Contact Name: __________________________________________________ Title: _______________________

Email: _____________________________________________________________ Phone: _________________

Employer ID or SS #: ________________________ Phone: ________________________ Fax: ______________

Project Name: ____________________________ Parcel#: __________________________ Acreage: _________

Project Address: ____________________________________________________________________________

Project Type: Residential __ Commercial __ Estimated Start Date: __________ Completion Date: _______________

Description: ________________________________________________________________________________

Authorized Signatory for SWPPP (Manager or above): _______________________________________________

Site Supervisor: ________________________________________________ Title: ________________________

Email: __________________________________________________________ Phone: ____________________

Dust Class Certification #: ___________________________________ Expiration Date: _____________________

Person responsible (on job site) for dust control: _____________________ And SWPP: _____________________

Water Source (circle all that apply): Water Truck - Hydrant - Jones Valve – Stand Tank – other ________________

Will there be offsite work? Y __ N __ Approved Plan # for offsite work: __________________________________

Description of Work Performed: Include Demo, Blasting, Crushing and Owners Designee (name, address, phone and email) __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________________________________________________________

Please include a copy of the soil report and a set of mini plans (10X17), for the preparation of the SWPPP.

Revised 05/21/13