V. FEE SUMMARY (for office use only) …

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2 _____CONSTRUCTION PERMITAPPLICATIONA pplicant Completes: Sections I, II, III (optional), IV, VI, and F100-1 (rev. 8/08)V. FEE SUMMARY ( for office use only )$1. Number of StoriesVI. BUILDING/SITE CHARACTERISTICS( office use only )3. Area Largest Floorsq. New Building Areasq. Volume of New Structurecu. Height of Structure VII. DESCRIPTION OF BUILDING USE A. RESIDENTIAL (primary use) 1. State Specific Use: 2. Use Group, Proposed: 3. Change in Use Group, Indicate Present: 4. No. of dwelling units: Gained, Sale Gained, Rental Lost, Sale Lost, Rental B. NON-RESIDENTIAL (primary use) 1. State Specific Use: 2. Use Group, Proposed: 3. Change in Use Group, Indicate Present: C. MIXED USE -List secondary use(s): D.

3 Construct. DOES OR WILL YOUR BUILDING CONTAIN ANY OF THE FOLLOWING?UpdateUpdate8. Subtotal$10. Subtotal$11. Cert. of $1. Building$ ProtectionElevator 20% for State Plan Permit Surcharge Fee7. Max. Occupancy Load6. Max. Live WORKDO YOU WANT:IIb. SUBCODES(Check all that apply)1. Partial Releases2. Prototype ProcessingIII. PLAN REVIEW (optional)TOTAL COSTP lansRec'd byDateRec'dRejectionDateApprovalDateRe-v iewer Resubmission Dates Approval RejectionRe-viewerEst. CostMinor Work New Building Addition DemolitionRepair Alteration Renovation ReconstructionAsbestos Abat.

4 -Subch. 8 Lead Hazard Abatement Radon Remediation Annual Industrialized Building:State ApprovedHUD Land Area Disturbedsq. Hazard Zone Flood Elevationft. yesnoTotal UnitsIncome-restricted Proposed Present1. Elevators/Escalators/Lifts/Dumbwaiters/M oving Walks2. High Pressure Boilers3. Pressure Vessels4. Refrigeration Systems5. Cross-Connections/Backflow Preventers6. Hazardous Uses/Places of Assembly7. Sprinklers/Standpipes8. Smoke Control Systems in Open Wells9. Underground Storage Tanks10. Swimming Pools, Spas and Hot Tubs11. LPGas Tanks12. Fire AlarmBuildingElectricalPlumbingFire ProtectionElevatorFOR office USE only (Optional) Person in Charge once Work has or No.

5 OR, if new home, Builder Reg. DateHome Improvement Contractor Registration No. or Exemption Reason Federal Emp. ID :PrivatePublicOwnership in Fee:zip IDENTIFICATIONP roposed Work Site at:Name of Owner in IN LIEU OF OATHI. 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 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 familyresidential use. I attest that all construction, plumbing, or electrical work will be done, in whole or in part, by me or bysubcontractors under my supervision, in accordance with all applicable laws; and, I further acknowledge that saidnew home is not covered under the New Home Warranty and Builders Registration Act ( 46:3B-1 et seq.)

6 Andthat such fact shall be disclosed to any person purchasing this property within ten years of the date of issuance of acertificate of UNDERSTAND THAT IN MARKING BOX A, I ACKNOWLEDGE THAT I AM ASSUMING RESPONSIBILITY FORTHE WORK DONE ON SAID PROPERTY, THE CONDITION OF THE PROPERTY PRIOR TO, DURING, AND AFTERANY WORK PERFORMED, AND FOR THE PERFORMANCE OF THE SUBCONTRACTORS I HIRE, EMPLOY, OROTHERWISE CONTRACT OR WITH WHOM I MAKE AGREEMENTS TO PERFORM WORK. I AM VOLUNTARILYAND KNOWINGLY ASSUMING THIS ( ) I further certify the following as required by the New Jersey Uniform Construction Code, 5 (f) :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 listedon Page 1; or, 3) a new structure that will be physically separate from, but that will be deemed part of, an existingsingle family residence that is owned and occupied by myself and located on the property listed on Page ( ) I further certify that I will perform or supervise the following ( ) ( ) Fire ProtectionI further certify that I will perform the following ( ) ( ) PlumbingD.

7 ( ) I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division ofTaxation and to comply with all New Jersey tax further certify the following as required by the Uniform Construction Code, 5 (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 givenprior to pemit issuance. I understand that if any of the above statements are willfully false, I am subject to 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, 5 (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 further certify the following as required by the Uniform Construction Code, 5 (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 givenprior to permit issuance.

8 I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of Taxationand to comply with all New Jersey tax understand that if any of the above statements are willfully false, I am subject to punishment.( ) Check if Name _____Address_____Telephone _____Signature_____III. ( ) LEAD HAZARD ABATEMENT: Include Homeowner or Building Owner Affidavit as per 5 (b) ( ) HOME ELEVATION: Include Home Elevation Contractor Certification as per 52 F100-2 (rev. 11/2014) DATE RECEIVED: _____VIII. PRIORAPPROVALSCHECKLIST( office use only )Zoning OfficerPlanning BoardZoning BoardSewer AuthorityWater AuthorityPolice DepartmentHealth DepartmentSoil Department ofCommunity Department Department ofEnvironmental ProtectionUtility Dig F100-3 (rev.)

9 12/07)IX. SUBCODES AND SPECIAL REGULATIONS APPLICABLE ( office use only optional)Name of Code & EditionName of Code & EditionBuilding _____ Energy _____ Other_____Electrical_____ Barrier Free _____ _____Plumbing_____ Flood Hazard _____ _____Fire Protection _____ As Built Elevation Cert. _____ _____Mechanical_____ Other _____ _____X. CERTIFICATES ISSUED ( office use only )DATE ISSUEDDATE EXPIREDDATE REISSUEDDATE EXPIREDT emporary Certificate of Certificate of Certificate of of of of Abatement Clearance