Application - Gas Station
NEW HANOVER COUNTY BUILDING PERMIT
APPLICATION TYPE: COMMERCIAL
PLEASE ANSWER ALL QUESTIONS APPLICABLE TO YOUR PROJECT
“Project Responsibility”
APPLICATION
Number
_________
(Office Use)
APPLICANT’S NAME: _______________________________________________________________ DATE: __________
DEVELOPER: _______________________________________________________________ PHONE #: ______________
PROJECT ADDRESS: _____________________________________ CITY: __________________________ ZIP: _____
OCCUPANT/BUSINESS NAME: ____________________________
PROPERTY OWNER’S NAME: ___________________________________________________ PHONE #: ______________
OWNER’S ADDRESS: ________________________________ CITY: ________________________ ST: __ ZIP: _____
CONTRACTOR: ______________________________________ LICENSE #: ____________ ACCOUNT #: ____________
ADDRESS: ________________________________________ CITY: ________________________ ST: __ ZIP: _____
EMAIL ADDRESS: ___________________________________________________________ PHONE #: ______________
PROJECT CONTACT PERSON: __________________________________________________ PHONE #: ______________
(Check All That Apply)
EXIST CONSTRUCTION: __ ALTERATION __ RENOVATION __ GENERAL REPAIRS __ RELOCATION
If Relocation, is there a Natural Gas Line on the Current Site? __ Yes __ No IS BLDG SPRINKLERED? __ Yes __ No
NEW CONSTRUCTION: __ ERECT NEW STRUCTURE __ FAST TRACK __ SHELL __ UPFIT __ ADD TO EXIST STRUCTURE
ACCESSORY STRUCTURE: _____________________________________________________________________________
If UPFIT – The Shell Permit #: _____________ Is Elect Power on this Building __ Yes __ NO
***** IS THIS A CHANGE OF OCCUPANCY USE? __ YES __ NO *****
IF Yes, what was the Previous Occupancy Type? _______________ What is the New Occupancy Type? _______________
ARCH DESIGN PROFESSIONAL: ________________________________________ PH: ______________ NC REG #: ____________
ENGR DESIGN PROFESSIONAL: ________________________________________ PH: ______________ NC REG #: ____________
DESCRIPTION OF WORK: _____________________________________________________________________________
Is food or beverages prepared or served in this structure? __ Yes __ No Is The Property Located In The Floodplain? __ Yes __ No
DISCLAIMER: I hereby certify that all information in this application is correct and all work will comply with the State Building Code and all other applicable State and local laws and ordinances and regulations. The NHC Development Services Center will be notified of any changes in the approved plans and specificationsor change in contractor or contractor information. ***NOTE: Any Work Performed W/O the Appropriate Permits will be in Violation of the NC State Bldg Code andSubject to Fines Up To $500.00***
OWNER/CONTRACTOR: ____________________________ SIGNATURE: ___________________________
(Qualifier) (Print Name)
Note: Demolition notifications & asbestos removal permit applications are to be submitted using the application form (DHHS-3768) whether the facility or building was found to
contain Asbestos or not. You are required to call the National Emission Standards for Hazardous Air Pollutants (NESHAP) at (919)707-5950 at least 10 days prior to the
demolition of any facility or building. See Asbestos Web Site: http://www.epi.state.nc.us/epi/asbestos/ahmp.html
TOTAL PROJECT COST: _____________ BUILDING HEIGHT: ______________ # OF UNITS: _______________
TOTAL AREA SQ FT : _________________ SQ FT PER FLR: ________________ # OF STORIES: _____________
TOTAL SQ FT UNDER ROOF: __________ # OF STRUCTURES: ________________ # OF FLOORS: ______________
ACRES DISTURBED: ______________ EXST LAND DISTURBING PERMIT? ___ YES ___ NO
NEW IMPERVIOUS AREA: ______________________ SQ FT EXISTING IMPERVIOUS AREA: ______________________ SQ FT
PROPERTY USE: __ OFFICE __ RESTAURANT __ MERCANTILE __ EDUC __ APT __ CONDO OTHER:_______________
WATER: __ CFPUA __ COMMUNITY SYSTEM __ WELL __ ZONING USE CLASSIFICATION: ________________
SEWER: __ CFPUA __ CENTRAL SEPTIC __ PRIVATE SEPTIC __ COMMUNITY SYSTEM
*** SEPARATE PERMITS REQUIRED FOR ELECT, MECH, PLBG, GAS EQUIP, PREFABS & INSERTS ***
PAYMENT METHOD: __ CASH __ CHECK (PAYABLE TO NHC) __ BILL ACCOUNT __ MC/VISA __ DISCOVER
*************************************************************************************************************
(FOR OFFICE USE ONLY) REVISED DATE 4/11/12
ZONE: _______ OFFICER: ________________ SETBACKS: F:_____ LH:_____ RH:_____ B:_____
Approval:________ City:________ DATE:________ FLOOD: _______ ________ ________ BFE+2ft=________
A V N
Comment:______________________________________________________________ PERMIT FEE: $_____________
16-2235