GAS PERMIT APPLICATION FORM - Superior Safety Codes

1 [date received stamp] [agency file no.] [eSITE PERMIT no.] GAS PERMIT APPLICATION form Development PERMIT No.: Other Permits Required (under separate APPLICATION ): Building Electrical Plumbing PSDSA pplication Date (mmm/dd/yyyy): Estimated Project Completion Date (mmm/dd/yyyy): PERMIT Applicant: Owner Contractor Value of Installation (labour and material): $ Owner Name: Mailing Address: City: Province: Postal code : Phone: Cell: Email: Fax: Contractor Name: Mailing Address: City: Province: Postal code : Phone: Contact Name: Cell: Email: Fax: Project Location: Municipality: Subdivision Name: Tax Roll No.: Street/Rural Address: Postal code : Lot: Block: Plan: LSD: Quarter: Section: Township: Range: West of: Directions: Description of Work: Work has not started Work is in progress Work is complete TYPE OF OCCUPANCY TYPE OF WORK NUMBER OF OUTLETS INSTALLATION Single Residential New Renovation Addition Furnaces: Natural Gas Multi-family Appliance Replacement Water Heaters: Propane Farm/Ranch Refill Centre Boilers: Commercial Manufactured/Mobile Home Fireplaces: Tank Size: Industrial Service Reconnection Dryers.

2 Institutional Grain Dryer Unit Heaters: Serial No.: Oil and Gas Accessory Building BBQs: Other: Other: Ranges: Temporary Heat: units Secondary Gas Line: Project Total BTU (excluding residential and farm): Other: Total: FOIP Notification: Personal information collected on this form is collected under the authority of section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. It is used for processing PERMIT applications , issuing permits, Safety Codes compliance monitoring, verification and program evaluation. The name of the PERMIT holder and nature of the PERMIT may be included on reports provided to a municipality or made available to the public as required or allowed by legislation.

3 Questions about this collection may be directed to ASCA Coordinators at 1-888-413-0099 or at Suite 500, 10405 Jasper Avenue, Edmonton, AB T5J 3N4. Journeyman s Name (print) Journeyman s Signature Homeowner s Signature (homeowner PERMIT only) Homeowner Declaration: By signing this APPLICATION I hereby certify that I own/will own and occupy this dwelling. Journeyman s Certification No.: Office Use Only PERMIT Fee: $ SCC Levy: Issuing Officer s Name: Total Cost: $ ($ or 4% of the PERMIT fee maximum $ ) Issuing Officer s Signature: Receipt No.: Designation No.: Cash Debit Cheque PERMIT Issue Date (mmm/dd/yyyy): Credit Card (attach signed credit card authorization form ) Superior Safety Codes Inc., 14613-134 Avenue NW, Edmonton, Alberta T5L 4S9 Phone: 780-489-4777 or 1-866-999-4777 Fax: 780-489-4711 or 1-866-900-4711 Email: (Please Specify)