Building Permit City of Chamberlain

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Legal Description of Construction Site

Subdivision

Lot

Block

Owner's Mailing Address

Contractor's Mailing Address

Type of Use of Building

Class of Work

Class of Work (2nd choice if needed)

Select N/A if not needed

Describe Work

(Include material type: wood, brick, etc.)

Valuation of Work

Please put dollar amount, no commas.

Special Conditions

NOTICE

This permit will expire if work or construction authorized is not commenced within ninety (90) days or construction is not substantially completed within Two (2) year from the date of issuance of said permit.

I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of the Chamberlain City Zoning Ordinance or any other federal, state, or local law regulating construction activities or the use of any property.

Signature of Contractor or Authorized Agent

First Name

Last name

Date

Month

Day

Year

Signature of Owner (if owner builder)

First Name

Last Name

Date

Month

Day

Year