APPLICATION FOR MECHANICAL PERMIT Complete all sections on both pages except for the two sections marked “For Office Use”. Application Date______PROJECT INFORMATION & LOCATION:

Project Type: □ Commercial, □ Multifamily, □ Residential Project Name:______

Work Type: □ , □ Fire Suppression, □ Mechanical Project Address______Unit/Suite/Floor______Zip Code______Locator/ Subdivision or Parcel No.______Building/Center Name ______Lot No.______

□ Unincorporated County, or Municipality______Fire District______

WORK DESCRIPTION: PERMIT NO. Brief description of mechanical construction scope of work:

OWNER/TENANT INFORMATION:

______Property Owner______

Last Name First Telephone Fax Email

Owner’s Address ______Street Address City State Zip Code Tenant/Business Name ______□Existing, □ New*

*If a New Tenant/Business indicate the Previous Tenant/Business Use ______

ARCHITECT/ENGINEER INFORMATION:

Name & Address Telephone Fax Email

If New Tenant/Business Indicate The Previous Tenant/Business Use ______

PRIMARY CONTACT INFORMATION IF OTHER THAN APPLICANT:

Name & Address Telephone Fax Email

APPLICANT CERTIFICATION & INFORMATION

I CERTIFY THAT I AM THE OWNER IN FEE OR AGENT AUTHORIZED TO APPLY FOR THIS PERMIT, THAT I HAVE AN AGREEMENT WITH THE OWNER/LESSEE TO PREFORM THIS WORK; AND THAT I AM AUTHORIZED TO AND DO CONSENT TO ENTRY ONTO THE PREMISES BY ST. LOUIS COUNTY EMPLOYEES FOR INSPECTION OF WORK PERFORMED UNDER THIS PERMT. THE SCOPE OF WORK INDICATED AND COST ESTIMATES ARE TRUE AND CORRECT.

IF A PARTIAL PERMIT IS BEING REQUESTED, I REQUEST AUTHORIZATION TO PROCEED WITH THE CONSTRUCTION INDICATED IN ORDER TO ALLOW CONSTRUCTION TO COMMENCE. I ACKNOWLEDGE THAT IF AUTHORIZATION IS GIVEN THAT I WILL BE PROCEEDING AT MY OWN RISK WITHOUT ASSURANCE THAT A PERMIT FOR THE ENTIRE WORK OR STRUCTURE WILL BE GRANTED. I AM RELEASING ALL LIABIITY, INDEMNIFYING AND HOLDING HARMLESS ST. LOUIS COUNTY, ITS OFFICERS, EMPLOYEES, AGENTS, AND ANY ASSIGNS FOR ANY EXPENSE, ERROR, OR OMIISSION RESULTING IN SUCH ISSUANCE. SHOULD IT BE DETERMINED AT ANY TIME BY ST. LOUIS COUNTY THAT THE AUTHORIZED CONSTRUCTION NEEDS TO BE REMOVED, MOVED, CORRECTED, OR MODIFIED IN ANY FASHION, THAN SUCH REMOVAL OR CORRECTIVE WORK WILL BE AT OUR EXPENSE. Contractor Name & Address Tel No. Lic # Signature

Fax # Date Printed Name Email

Applicant Other Than Contractor □ Owner, □ Architect, □ Engineer, □ Tenant, □ Other ______Name & Address Tel # Reg # Signature

Fax # Date Printed Name

Email Note: Licensed Contractor must sign application before permit can be issued. Page 1 of 2 (Print/Copy As A 2-Sided Document Is Preferred) TYPE OF WORK TYPE OF STRUCTURE

New Construction RESIDENTIAL MULTI-FAMILY COMMERCIAL NON-HABITABLE Addition Alteration Single-Family 3 or 4 Multi-Family ASSEMBLY Antennas Replacement Two-Family 5 or more Multi- Theatres Attached Family Repair (s) Restaurant Barn Night Club Units/ ______Churches/Religious Detached Garage Shell Units/Permit______Recreation Center Fence Interior Finish Note: Two-Family and Note: Multi-Family Exhibition Fire/Storm Damage T ownhouse type buildings have common areas such as Banquet Center Generators must have independent common entry , corridors, Occupancy dwelling units with individual hallways, breezeways, and/or Taverns & Bars Cover Miscellaneous Work entrances. No common areas. common areas. BUSINESS Patio// Office/Bank/Professional Pergola MECHANICAL Carwash Res. Greenhousee Clinic Retaining Conveying Equipment: Fire Suppression: Pressure Vessels: Fire Station Shed Auto Lift……….# ____ Buildin g Sprinklers.#____ Boilers: Doctor’s Offices Signs Conveyor………# ____ Kit Hood Suppress..#____ Low Pressure……#____ Laboratories Panel/Array Crane…………...#____ Other (explain/list below) High Pressure……#____ EDUCATION Dumbwaiter……# ____ Non Potable Tank…#____ Schools Tanks Elevator….……..#____ HVAC Systems: Other (explain/list below) Child Day Care Tower Escalator………..#____ Air Conditioning: FACTORY/INDUSTRIAL Trash Enclosure Material Lift……#____ Total Tons ______Process Piping: Manufacturing Plant Other Platform Lift.…...#____ Heating System(s): Type______Industrial Laboratories Stairway Lift……#____ Total MBH______(Fuel, Gas, Hydronic, Med. etc.) Utilities Parking Lot Other (explain/list below) HVAC Equipment: HIGH HAZARD Air Handlers/ERU..# ____ Other Components: Flam. & Comb. Liquids FOR OFFICE USE Exhaust Systems: Chiller……………# ____ Duct Work…………#____ Storage or Manufacturer Gov’t / Public Owned Condenser…………#____ Fire/Smoke Dampers#____ Tire Storage (Bulk) Dryer……………#____ PERMIT FEES Fan Exhaust……..#____ Cooling Tower…...# ____ Flue Replacement….#____ Other High-Hazard Hood(s): Evaporator Cooler..# ____ Refrigerant Line(s)...#____ Storage or Manufacturer Processing ______Type I Hood….#____ Fan Supply………..#____ Registers/Diffusers...#____ INSTITUTIONAL Mechanical ______Type II Hood…#____ Forced Air Furnace.#____ Other (explain/list below) Nursing Inspection ______Day Nurseries Res. Kit. Hood..#____ Infra-Red Heater …#______Makeup Air Unit…#____ Other Equipment: Hospitals Med Gas Exhaust.#____ Penalty ______Motor Exhaust.….#____ Radiant Heat…….. #____ Fireplace…………..#____ Jails Paint Spray Booth.#____ Single Package Unit#____ Fuel Dispenser…….#____ Residential Care and Total Fees ______Smoke or Fume….#____ Solar Heat…………#____ Gas Logs…………..#____ Assisted Living Filing Fee Pd ______Other (explain/list below) Unit Heater…….….#____ Generator (Emerg)...#____ MERCANTILE Other (explain/list below) Kit Equip (Comm)...#____ Retail/Wholesale/Stores Balance Due ______UG Fuel Tank(s)….;#____ Service Station Fees Paid ______Other (explain/list below) Markets RESIDENTIAL Special & Other Items: Date Description ______Quantity ______Issued _____/_____/_____ Hotels/Motels Description ______Quantity ______Issued By ______STORAGE Description ______Quantity ______Office/Warehouse APPROVALS & DATE Description ______Quantity ______Lumber Yard Est. Cost ______Code Correction Work: ______Repair Garage Parking Garage Plan Rev. ______Inspections Required: One, Two, > Two, Provide # Req’d ______Box No. ______Comments/Information: ______Folder Other Permit References: ______Estimated Cost of Mechanical Construction Work: $______FOR OFFICE USE Record Check______Violation Check______Transient Employer Documents Notified______Date______#OP______PA Flat Permit No.______Page 2 of 2 (Print/Copy As A 2-Sided Document Is Preferred) K:\Permdata\Permit App Forms\MECHANICAL - 2014.docx 01/15/15