Construction

BID #: N/A

DUE: TBD

VALUE: TBD

100

Rating

Risk Rank

Green Risk

AI-Powered Lead Insights

AI Summary is being generated. Check back shortly.

Web Content

Office of Community and Economic Development
Resources
Agendas, Resolutions & Minutes
Financial Documents
Mayor’s Message
OPRA
Pay your Taxes online
Photo Gallery
Township Administrator’s Message
Township Committee
Departments
Construction
Code Enforcement
Finance
Municipal Court
Office of Community and Economic Development
Parks and Recreation
Public Works
Police
Recycling
Tax Assessor/Collector
Township Clerk & Registrar
What Dep’t Do I Need
Office of Community and Economic Development
The mission of the Cinnaminson Township Department of Community and Economic Development is to bring to fruition the community’s vision for its future quality of life, economic viability, and land use stewardship. Employing a strong customer service ethic, the Department emphasizes cooperation and interaction with business owners, residents, and developers to move projects from the design phase through the required approvals and on to completion. To accomplish this task, the Department brings all of the various stakeholders in the approval process together under one roof, including the Planning Board, Zoning Board of Adjustment, Construction Office, and Engineer. The Department is responsible for economic development and redevelopment initiatives, code enforcement, and property maintenance code enforcement so that properties which have fallen into disrepair can be addressed before negatively impacting the community’s quality of life.
Variance Application
Current and Prospective Business Owners:
Cinnaminson Township's Economic Development Committee provides important guidance and assistance to current and prospective business owners. If you are interested in expanding your business or bringing your business to Cinnaminson, please contact Eric Schubiger, Township Administrator at (856) 829-6000, ext. 2398.
Click here to Register/Renew Business Registration or Apply for Zoning Permit
Burlington County Small Business Loan Program
The Burlington County Department of Economic Development has a Small Business Loan Program for Burlington County Small Businesses. Click below for more information.
The Freeholders are offering, through the County’s Small Business Loan Program, COVID19 loans for working capital up to $50,000 to sustain small businesses through the pandemic.
A quick summary of our terms:
• Application fee is being waived for working capital to retain/hire employees or purchase inventory to sustain the business
• Repayment deferred until Aug. 1, 2020
• Current interest rate is 2.4375% for maximum 10 years
Below is the application which also can be accessed through the Bridge Commission’s website
Burlington County COVID19 Resources
Burlington County Small Business Loan Program
Burlington County Home Improvement Loan Program
What is the Home Improvement Loan Program?
Burlington County receives an allocation of Community Development Block Grant (CDBG) funds each year from the Federal government to provide assistance to residents of Burlington County through a variety of local housing-related and public service projects.
The Board of Chosen Freeholders has designated portion of these funds to be made available through the Home Improvement Loan Program, which is administered by Community Development and Housing.
The Home Improvement Loan Program provides technical assistance to qualified homeowners and makes 0 % interest property improvement loans of up to $20,000 to correct substandard housing conditions and to eliminate health and safety hazards.
Examples of eligible work include foundation, plumbing, heating and electrical repairs, roof work, termite and dry-rot repairs, water and sewer hookups, energy conservation measures and remodeling to provide wheelchair accessibility.
Loans are made for the rehabilitation of owner-occupied single family houses only. Technical assistance provided through the program includes assessing the scope of needed repairs, consulting with building officials, architects and other professionals as needed, assisting the homeowner in obtaining bids and contracting for the repairs, monitoring construction and issuing payments
Burlington County Home Improvement Program
Construction
Attention Cinnaminson Township Residents
This office performs all duties and responsibilities as required by the Uniform Construction Code, the International Construction Code, the New Jersey Department of Community Affairs, and laws pursuant to the New Jersey Uniform Construction Code. This office follows the requirements under the DCA and Cinnaminson codes
Municipal Construction Permits WILL NOT be issued without proof of registration from any contractor working on your home. Application packets are available at: Cinnaminson Township Construction Office, or by calling Consumer Affairs at 1-888-656-6225 Or Online at:
http://www.njconsumeraffairs.gov/HIC/
Home improvements include the construction, installation, replacement, or repair of residential driveways, sidewalks, swimming pools, terraces, patios, additions, landscaping, fences, porches, windows, doors, cabinets, kitchens, bathrooms, garages, finished basements, basement waterproofing, fire protection devices, security protection devices, central heating and air conditioning equipment, water softeners, heaters, and purifiers, solar heating or water systems, insulation installation, roofing and siding, wall-to-wall carpeting or attached or inlaid floor coverings, and more.
Requesting a Construction Permit
Construction Permit Fees (see Township Code Book Chapter 265-7):
Construction Permit Application
Construction Permit Forms
Building Subcode
Electrical Subcode
Fire Subcode
Mechanical Subcode
Plumbing Subcode
Chimney Certification
Supplemental Structures Permit Application - Zoning Department
(Sheds under 200 sq. feet, Fences that do not enclose a pool) see Township Code Book Chapter 125-102.1:
Supplemental Structure Permit Application
Permits and Licenses
When is a Permit Needed?
A Construction Permit, which may include a Building, Electrical, Fire and/or Plumbing sub-code technical section, is required to do any of the following:
All construction, including but not limited to:
(The following is a general guide – each job may have different requirements and may need more than is listed below)
Construction permit applications for projects which change the footprint of the building, lot coverage, use of the space, etc. may also require a Zoning approval
Additions:
Building, Electrical, Plumbing, Fire include Survey for Zoning
New Buildings:
Building, Electrical, Plumbing, Fire include Survey for Zoning
Air Conditioning:
Electric & Mechanical
Pod:
Contact Zoning Office
(856)829-6000 ext. 2313/2396
Alarms:
Burglar: Electric
Fire/Smoke/Carbon Monoxide: Electric & Fire
Pool (In Ground/Above Ground/Temporary/Seasonal)
Building, Electric, Plumbing, Fire (for heater) include Survey for Zoning
Alterations:
Residential/Commercial – Building, Electrical, Plumbing and/or Fire
Porch:
Building include Survey for Zoning
Asbestos Removal:
Building
Radon:
Building & Electric
Basement Refinishing/Remodeling:
Building, Electric, Fire and/or Plumbing
Ramp
Building include Survey for Zoning
Bathroom Fixtures:
Direct replacement and/or any piping changes
– Plumbing
(Need licensed plumbing contractor or Homeowner)
Roof:
Building (Commercial only)
Chimney Liner:
Building
Shed
(200 sq. ft or less - contact Zoning office
over 200′sq. ft.– Building
Deck:
Building include Survey for Zoning
Siding:
Building (Commercial only)
Demolition:
Building
Signs:
Building & Electric
Doors:
(Adding, Enlarging or Eliminating) – Building
Dumpster:
No permit required MUST BE IN DRIVEWAY
Spa/Hot Tub:
Electric include Survey for Zoning
Sprinkler System: (Interior)
Fire
Electric Work:
Landscape Lighting, All Voltages
Steps
Building include Survey for Zoning
Elevator:
Elevator
Tank:
(Installation, Abandonment or Removal) Fire
Fence:
Around a pool, over 6′ or Commercial – Building
Residential without a pool - contact Zoning Office
Telephone/Comm. Points/Voice Data/Computer Wiring:
Electric
Fireplace:
Building, Fire, Mechanical & Chimney Certification
Garage:
Building (Others as needed) include Survey for Zoning
Tenant Fit Out:
Building, Electrical, Plumbing and Fire
Contact Zoning for New Business information
Gazebo:
Building include Survey for Zoning
Trailer/Construction/Building/Sales:
Building & Electrical
Generator:
Electrical & Mechanical include Survey for Zoning
Heating/Vent/HVAC:
Electric (if fuel fired equip.
does not need licensed electrician)
& Mechanical
Water Heater:
Mechanical for residential replacement
Plumbing for commercial or new construction
Wood burning Stove:
Building & Fire
Hood:
Fire & Electric
Irrigation/Lawn Sprinkler:
Electric unless wireless, Plumbing for Backflow preventer
Moving a structure:
Building & all utility sign-offs as for demo (Also would require footing/foundation
application for setting the structure in new location)
Building Codes
Please refer to the
Uniform Construction Code Book
or
Current Adopted Codes
for more detailed information about building codes.
Building Inspections
1621 Riverton Road
Cinnaminson, NJ 08077
Phone: 856-829-6000 ext 5
Fax: 856-303-0265
[email protected]
Inspectors
Position
Brad Regn
Construction Code Official/ Building Sub code
Lori Neely
Technical Assistant
Robert Yearly
Building Inspector
Robert Yearly
Fire Inspector
Anthony Cimino
Plumbing Inspector
3rd Party
Electrical Inspector
Inspection Hours:
Construction Official: Tuesday & Thursday 2:30 pm to 5:00 pm
Building: Tuesday & Thursday 8:00 am to 12:00 pm and 5:00 pm to 7:00 pm
Electrical: Monday to Friday 7:00 am to 11:00 am
Plumbing: Monday & Thursday 8:00 am to 12:00 pm
Fire: Tuesday & Thursday 8:00 am to 12:00 pm
Obligations During Construction:
Any work which does not conform to the approved plans will require re inspection. If the work continues without resolving the problem, the applicant will be fined and the job stopped.
Applicants are required to post the permit prominently on the site and to keep a copy of the approved plans at the site.
When the project is completed, the applicant must call for final building, electrical, plumbing, and fire inspections prior to occupying.
State law mandates that the Construction Official issue a fine to any person who performs work without a permit if the construction is of a nature which requires a permit.
Construction Code Official – Michael Lunemann
Code Enforcement
The Property Maintenance Code (Chapter 405) is used to protect the health safety and welfare of the general public by establishing minimum standards for the maintenance of premises throughout the Township. It covers many areas, such as but not limited to, overgrown grass and vegetation, residential and commercial parking requirements, trash and refuse, exterior maintenance for buildings, parking lots, curbs, and sidewalks, infestation, clothing bins, and dumpsters. The Code Enforcement Officer investigates reported violations of Chapter 405. He can be reached at 856-829-6000 ext. 2379.
Frequently Asked Questions about Code Enforcement & Zoning
Are permits required for fences, sheds, pools, hot tubs, and decks?
Yes, permits are required regardless of the size and height. A copy of your survey is required, showing the location of the proposed structures.
Do I need a Certificate of Occupancy Inspection to sell my home?
No, Cinnaminson Township does not require CO inspections for resale of a residential home. They do require an inspection from the Sewerage Authority (856)829-5287 and the Fire District (856)829-5220. Please contact them directly for scheduling and fees.
Am I required to keep my lawn mowed?
Yes, Township ordinances require that the lawn be maintained and may not be higher than 8”.
Am I permitted to place signage on trees or utility poles advertising my yard sale? Do I need a permit for a yard sale?
The Twp. ordinance requires that you notify the Zoning Officer of your intent to have a yard sale. There is no fee for approval of a yard sale. You are NOT permitted to place signage of any kind on trees or utility poles, however the Zoning Officer will extend you the courtesy of allowing temporary. signs for a limited time, which must be removed after the sale.
Are temporary pools permitted?
Yes, however State law requires that any body of water 24” or deeper MUST BE surrounded with a minimum 4’ barrier (fence or wall) which meets the State code. Not all types of fence meet the State Code.
Am I responsible to maintain my sidewalks, curbs, and grass strip between them?
Yes, the ordinances require you to maintain all of the area between your property line and the street, including the sidewalks, grass strip, and curb. This also pertains to the areas behind the homes with reverse frontage that back up to roadways. This includes snow and ice removal within 24 hours of the snow event.
When can I put my trash out?
Trash may not be put out before 12pm (noon) the day before the scheduled trash collection day.
Am I permitted to park vehicles, boats or trailers on my lawn?
No, vehicles (only) must be parked in the driveway (or street if legally registered). Vehicles, boats, and trailers not parked in the driveway MUST BE parked in the rear yard a minimum of 5’ from the property lines, and MUST BE placed on a hard surface such as asphalt, stone, or concrete with a thickness capable of supporting the weight.
Are permits required for a new roof, windows, siding, and other home improvements?
Yes, under most circumstances. There are some exceptions for very minor repairs. The best thing to do, is to call the Twp. Construction Dept. at 829-6000 ext 2312.
Are storage PODS permitted?
Yes, for purposes of temporary (30 days) storage, and they do require a permit, and must be placed in the driveway.
Are dumpsters permitted to be placed in the street during construction?
NO, dumpsters are NOT permitted to be placed in any street under any circumstances. They present a danger to motorists.
What do I do with my grass clippings?
Grass clippings should be placed in your Cinnaminson Township trash container for regular trash collection.
Do I need to put my house number on my house or mailbox?
All buildings MUST be numbered so that emergency personnel can see your address from the street.
Zoning
Zoning Board of Adjustment:
The Zoning Board of Adjustment has the authority to hear and decide appeals of any order, requirement, decision or refusal made by the zoning officer based or made on the provisions of the Township’s zoning ordinance. In addition, the Zoning Board of Adjustment hears and decides requests for interpretation of the zoning map or ordinance. A Zoning Ordinance (Chapter 525) is used to regulate and limit the uses of land, as well as the uses and locations of buildings and structures on a particular lot. Cinnaminson Township has nine different Residential Zones, and six different Commercial/Industrial Zones; each with its own set of requirements. Each Zone has a number of “bulk” requirements which include the maximum building height permitted, the minimum lot size required, the minimum setback to all property lines, and the maximum lot coverage by buildings. The Zoning Officer enforces the Zoning Regulations as defined in Chapter 525 to ensure the proper use of buildings and lands throughout the Township. The Zoning Officer can be reached at 856-829-6000 ext. 2396. The Cinnaminson Township Zoning Board of adjustment meets on the first Wednesday of each month at 6:30 PM in the Township’s Municipal Building. To schedule an appearance with the Zoning Board of Adjustment, please contact Zoning Board Secretary at 856-829-6000 ext. 2313.
Appearing Before the Planning Board and/or Zoning Board
Planning Board:
The Cinnaminson Township Planning Board is tasked with ensuring that the Township’s Master Plan regarding development is followed. The Board will also make amendments to the Township’s Master Plan on an as needed basis. The Board processes and approves all applications for site plans in accordance with the provisions of the Township code. The Board also acts on variances and certain building permits in conjunction with subdivisions, site plans and conditional use approval pursuant to the States Municipal Land Use Law. The Planning Board meets on the 2nd and 4th Tuesday of each month. To submit an application to the Planning Board, please contact Ms. Patricia Rucci at 856-829-6000 ext 2313.

Document Text

--- Document: Variance Application ---
Township of Cinnaminson
VARIANCE INSTRUCTIONS
IMPORTANT: In order to expedite the process of the application, the applicant should be careful to
comply fully with all instructions.
1. Secure from the Zoning Officer a denial form (BA-1) which will state the section and article
numbers of the ordinance, and reasons for the denial of the permit. The Zoning Officer will
give you the application forms package. It is a two-part process, which will be explained to
you when you receive the package.
2. If you are not the owner of the property, a letter of authority from the owner is required.
3. Attach in triplicate, drawn to scale, a survey / plot plan depicting the following:
A. Dimensions and area of lot, including Title Block
B. Existing and proposed structures with dimensions and proposed setbacks.
C. Driveways and parking areas if applicable.
4. Attach in triplicate, a copy of the tax map showing subject property, and those properties
located within 200', including any in other towns.
5. The first part of the completed applications (BA-2 pgs. 1,2, &3), accompanied by
Architectural plans/prints, must be filed with the Zoning Officer AT LEAST 21 days prior to
the next regularly scheduled monthly meeting. Cash or Check MUST accompany
application. ("C" $45,00, plus $400.00 Residential/$600.00 Commercial. "D" $75.00, plus
$400.00 Residential/$1,200.00 Commercial, and $0.25 per name or $10.00, whichever is
greater, for the required list of property owners and utilities within 200' of the subject
property.
6. Zoning Officer will assign a case number upon receipt of the completed first part of the
application (BA-2 pgs. 1,2&3) with required fees. You will be given a hearing date and time
so that you can serve Notice to Property Owners (BA-4) and also post a notice in the Official
Newspaper (also BA-4). This notification must be done at LEAST 10 DAYS PRIOR to the
hearing date to be in compliance with State Law. The newspaper MUST PRINT the Notice at
LEAST 10 DAYS PRIOR to the hearing date as well. If notification is not done in time, or
done improperly, you will NOT be heard, and may be required to re-notice the entire list.
7. Submit the following to the Zoning Office at LEAST 5 DAYS prior to the meeting:
A. Form BA-5 pages 1 and 2 (part 2 of the application)
B. Copy of page BA-4, "Notice To Property Owners"
C. Original certified receipts (if method of service)
D. Affidavit of notice placed in Official Newspaper
8. The applicant or his agent must be in attendance at the hearing. A CORPORATION OR
PARTNERSHIP MUST BE REPRESENTED BY AN ATTORNEY.
9. The action taken by the board will be advertised in the newspaper after the decision is made.
Said decision will be available for inspection in the Board Secretary's office.
10. The Secretary will send copies of the Resolution to the applicant and Applicant's attorney
after memorialization.
TOWNSHIP OF CINNAMINSON
Municipal Building
1621 Riverton Road
Cinnaminson, NJ 08077
Dear Mr. DeKlerk,
I am requesting a property owners list of properties located with 200' of
Block Lot in Cinnaminson Township.
I understand that per the Township ordinance, the fee shall be $.25 per name, or $10.00,
which ever is greater.
I will pay the required processing fee to the Zoning Office prior to
receipt of the requested list.
I have paid the required processing fee to the Zoning Office.
You may reach me at the following number and I will pick up the list.
Kindly mail the above list to the address below:
Thank-You,
***** Please furnish a copy of my list of property owners to the Planning and Zoning
Office.
TOWNSHIP OF CINNAMINSON, NEW JERSEY
BOARD OF ADJUSTMENT/PLANNING BOARD
ZONING OFFICER'S DENIAL
Note: In setting forth the reasons for denial, describe same in words and also refer to the sections of
the ordinances or statutes violated.
TO:
PHONE#
EMAIL
Your application for:
Certificate of Occupancy
Building Permit
On premises located at
Known as Block
on this
Lot
Subdivision
Use
and
Zone has been denied
In a
20
for the following reasons:
Statement of Violation
Violation of:
Article No.
Section No.
Zoning Officer
Note: If the applicant seeks relief from the denial of the application this instrument may not be relied upon as setting forth all
violations of the Ordinance. The responsibility for setting forth all sections of the Ordinance from which relief is sought remains
upon the applicant. Any appeal from this denial must be made within thirty days of the issuance of the denial.
Attorney representing applicant - name and address (if applicable)
Phone #
EMAIL
ESCROW AGREEMENT
The undersigned hereby acknowledges the initial escrow fee required for professions to
review a
and the application fee in the amount of $
application.
in the amount of $
is required upon filing the
The undersigned acknowledges that there MAY BE ADDITIONAL charges over and
above the initial review fees deposited.
In the event that the professional review fees exceed the sum of $
the
undersigned hereby agrees to pay any additional professional review fees within 10 Days
of notification.
In the event that the escrow fees deposited by the undersigned exceed the amount of
professional review fees, the excess fees shall be refunded without interest.
In the event the undersigned shall dispute any review fees charged by the professionals,
the undersigned shall deposit the escrow fund with the Township of Cinnaminson within
10 Days from receipt of billing of same and shall have the right to request the appropriate
Board to hear their complaint at a regularly scheduled meeting and decide the issue.
The undersigned agrees to be responsible for all bills against this developments escrow
account. In the event that this project is sold or my interest is transferred to another
party, my obligation can only be relieved if all outstanding escrow bills are paid and the
new principal obligates himself to the responsibility of all future bills in an agreement
with the Township.
Owner
Applicant (If different than owner)
Address
Address
Phone Number
Phone Number
Email
Email
The undersigned is the responsible party for the escrow deposits:
Print Name
Signature
BA2 pg. 1
Case #
Date filed
Fee paid
Paid to
TOWNSHIP OF CINNAMINSON
ZONING BOARD OF ADJUSTMENT
PLANNING BOARD
APPLICATION FOR HEARING
-Request is hereby made for:
A. Review and determination of an order, requirement, decision of refusal
by an administrative officer or agency, based on Articles(s)
Section(s)
of the Zoning Ordinance.
B. Permission to (erect) (alter) (convert) (use) (subdivide) a
(contrary) (pursuant) to the requirements of Articles(s)
Section(s)
of the Zoning Ordinance upon the premises
Known as (street address)
_, and designated as
Block
Lot
on the Official Tax Map of the Township of
Cinnaminson, in a
Zone, in accordance with plans attached.
The proposed building, subdivision, or use therefore is contrary to the Ordinance
or constitutes a special exception use in the following particulars. The following
is a description of the proposed building and premises.
1. Name of Applicant
2. Address of Applicant
3. E-Mail Address:
Phone Number
4. Name of Property Owner (if different than applicant)
5. Address of Owner
6. Phone # of Owner
E-Mail Address
7. Name of Attorney
8. Attorney phone number
E-Mail address
9. Date Title Acquired
10. Name of Lessee
11. Use of proposed building and premises
12. Dimensions of Lot
Area of lot
Sq. Ft.
acre
BA-2 pg.2
13. If less than the entire lot is to be utilized for the purpose here in set forth, the
Dimensions of the portion of the lot to be utilized are
The area of the lot to be utilized
(square feet)
14. Size of the proposed building
At street level:
Feet front
Feet deep
Height: Feet
Stories No.
15. Use of existing building or premises
Has the Zoning Officer or Building Inspector examined the plans for the proposed
building and refused a building permit? YES
NO
Attached is a copy of the Zoning Officer's (form BA-1) denial.
Has there been any previous appeal involving these premises?
If so, state date of filing, character of appeal and disposition of same
Check the particular section of the state statute under which this application is
A. Appeal from decision of Zoning Officer
B. Special Reason
C. Hardship
D. Use Variance
The following arguments are made in support of this Appeal:
(If more space is needed, attach separate sheet)
BA2 pg.3
ATTACHED HERETO AND MADE A PART OF THIS APPEAL ARE
SUBMITTED THE FOLLOWING PAPERS:
1. Three sets of drawings, drawn to scale, and containing all necessary
measurements and all features involved in the appeal. (See Item 3, under
Instructions)
2. Plot plans in triplicate, drawn to scale, showing dimensions and area of
property in question and all properties within 200 feet of said property
(see item 4 under Instructions)
3. A letter of authority, or power of attorney, in case the appeal is made by a
Person other than the actual owner of the property.
I hereby depose and say that all the above statements and the statement
contained in the paper submitted herewith are true and correct.
Sworn and subscribed to
Before me this
Day of
Signature of Applicant
Address
NOTE: It is the responsibility of the applicant to specify in this application all
requests for relief from any section of the ordinance he may need. Should any
unspecified violation be found prior to or during the course of a public hearing
NO such relief can be granted and the case cannot be permitted to proceed
without re-advertising and reserving notices. If the failure is not discovered by the
Board until it commences its deliberation after closing the public hearing, the
result may be a denial of the entire application, or the grant or recommendation
that the variance be granted limited to the specific relief requested, which will
result in the necessity for a re-application to obtain the remaining relief required.
BA-5, Pg. 2
Method of Service
A- Hand Delivered
B- Certified Mail
METHOD
OF SERVICE LOT# BLOCK# NAME
A or B
ADDRESS
DATE
OF
SERVICE
(Attach Additional Form if Space is Insufficient)
Sworn and subscribed to before me
This
day of
20
Signature of Server
BA5 pg. 1
TOWNSHIP OF CINNAMINSON
VARIANCE APPLICATION
In the matter of the Application
Of
STATE OF NEW JERSEY,
COUNTY OF BURLINGTON
I,
being duly sworn on my oath, depose and say, that I am
the (applicant), (owner) or (agent of the owner) (strike out inapplicable words) that at the
date hereinafter stated, I served notice of which the below is a try copy, upon the
following property owners, each of whose property is within 200 feet of the property of
appellant to be effected in this matter, in the manner following, that is to say,
(A) Personally, by handing such true copy to said property owners, being resident
of the Township.
(B) By mailing, by certified mail, such true copy to the last known address of the
Property owners as shown by the most recent tax list of said Township, said
Persons being resident of said Township.
RE: Case #
FORM OF NOTICE
Please take notice that the undersigned has appealed to the
Planning Board
Zoning Board
Of the Township of Cinnaminson for a variance from the provisions of section
of the Zoning Ordinance so as to permit
On premises located at
Known as Block
Lot
on the Tax Map, which is within 200 feet of
property owned by you. This appeal is now on the Secretary's Calendar, and a public
hearing has been ordered for
evening,
at 6:30 p.m.
prevailing time, in the Municipal Building, 1621 Riverton Road, Cinnaminson, New
Jersey, at which time you may appear either in person or by agent, or attorney, and
present any objection which you may have to granting of this appeal.
This notice is served upon you by order of the
Planning Board
Zoning Board
Respectfully,
Applicant
Applicant
BA-4
CINNAMINSON TOWNSHIP
ZONING BOARD OF ADJUSTMENT
OR
PLANNING BOARD (AS APPLICABLE)
NOTICE TO PROPERTY OWNERS
TO:
Date of Service
Case #
Please take notice that the undersigned has appealed to the reviewing Board for (give
details)
and any other variances or waivers deemed necessary by the Board.
In violation from the provisions of Article(s)
Section(s)
of the zoning ordinance, on premises located at
known
as Block
Lot
, on the Tax Map, which is within 200' of property
owned by you. This appeal is now on the Secretary's calendar for public inspection and a
hearing has been set for
evening,
20
at 6:30 pm
prevailing time, in the Municipal Building, 1621 Riverton Road, Cinnaminson, N.J., at
which time and place you may appear either in person or by agent or by Attorney and
present any objection which you may have to granting this appeal. This Notice is served
on you by order of the reviewing Board.
Applicant
Applicant
NOTE: All property owners within 200' must be served at least 10 days prior to the date
set for the public hearing (not including the hearing date), as well as utilities, and a public
notice in the newspaper. In addition, notice is required to the State Department of
Transportation or Burlington County Planning Board if property is located on a State or
County roadway.

--- Document: Burlington County Home Improvement Program ---
Department of Human Services
Community Development & Housing
Burlington 
County
Home 
Improvement 
Loan Program
Repair Your
Home... Brighten
Your Outlook
Sponsored by the 
Burlington County 
Board of Chosen 
Freeholders
What is the Home Improvement  
Loan Program?
Burlington County receives an allocation of Community 
Development Block Grant (CDBG) funds each year 
from the Federal government to provide assistance to 
residents of Burlington County through a variety of local 
housing-related and public service projects. 
The Board of Chosen Freeholders has designated a 
portion of these funds to be made available through 
the Home Improvement Loan Program, which is 
administered by Community Development and Housing.
The Home Improvement Loan Program provides 
technical assistance to qualified homeowners and makes 
0 % interest property improvement loans of up to 
$20,000 to correct substandard housing conditions and 
to eliminate health and safety hazards. 
Examples of eligible work include foundation, plumbing, 
heating and electrical repairs, roof work, termite and 
dry-rot repairs, water and sewer hookups, energy 
conservation measures and remodeling to provide 
wheelchair accessibility. 
Loans are made for the rehabilitation of owner-occupied 
single family houses only. Technical assistance provided 
through the program includes assessing the scope 
of needed repairs, consulting with building officials, 
architects and other professionals as needed, assisting 
the homeowner in obtaining bids and contracting for the 
repairs, monitoring construction and issuing payments.
Human Services Department
The Department of Human Services consists of a wealth 
of services to support individuals in the community 
from all backgrounds, with various needs. We strive to 
provide one-stop human service shopping, a building 
in which all county residents find a wealth of resources 
working together to help them find their strength, resil-
ience and direction into a brighter tomorrow. Through 
the recent reorganization, the merged Department is the 
platform from which we bring existing skills together 
to tackle some of our thorniest community issues with 
comprehensive planning and monitoring. 
- Shirla Simpson, Director
Human Services includes the following Divisions: 
•
Office on Aging
•
Division of Behavioral Health and Youth Services
•
Division of Community Development & Housing
•
Division of Employment & Training
•
Business and Job Seeker Services
•
Workforce Investment Board
•
Division of Veterans & Military Services
Human Services works closely with the following:
•
Advisory Council on Women
•
Board of Social Services
Department of Human Services 
Human Services Facility 
795 Woodlane Road 
Westampton, NJ  08060 
 609-265-5800    •   Fax: 609-265-5382 
 Email: HumanServices@co.burlington.nj.us 
  Hours: Monday thru Friday  -  8 am - 5 pm 
“The Fair Housing Act prohibits discrimination in housing 
based on color, race, religion, national origin, sex, familial 
status or disability.”


What Are The Eligibility Requirements?
You could be eligible if:  
•
You are the legal owner of the property in need of
repair: and
•
You reside there as your principal residence; and
•
The property is located in a participating
municipality; and
•
Your total household gross annual income is
within the following income limits established for
Burlington County by the Federal government:
Size of Household Maximum Annual Gross Income 
(Effective Date: June 1, 2018)
1
$48,950
2
3
4
5
6
7
8
$55,950
$62,950
$69,990
$75,500
$81,100
$86,700
$92,300
Applicants who meet the income guidelines established 
for Burlington County by the Federal government, may 
be eligible for a deferred payment loan.
"Gross annual income" is defined as the total annual 
amount of salaries, wages, tips, assistance grant child 
support, social security benefits, earned interest, 
dividends, etc. before deductions and taxes, received by 
the entire household.
What are the terms of the loan?
No monthly loan payments are required, and repayment 
of the loan amount is deferred until there is transfer of 
title or death of the borrower and reviewed periodically.
The interest rate for individual rehab loans are 0% per 
annum, simple interest.
The maximum loan amount is $20,000. Loans are 
limited to single family dwellings. All loans are secured 
by a promissory Note and a Mortgage which will be 
recorded and will become a lien on the property.
The loans may be paid in full without penalty.
The loan is not assumable. The loan is due and payable 
upon the death of the borrower. Should the property 
be sold during the life of the loan, or should title to the 
property change for any reason, or should the property 
become other than a single family owner occupied 
dwelling, the outstanding loan balance will become due 
and payable.
How is your application processed?
The loan process involves the following steps:
•
The applicant is interviewed by staff from the
Community Development Office to determine
preliminary eligibility and to explain how the
program works.
•
Upon the receipt and review of all documents,
including verification of employment, title search
and credit checks, the applicant will be notified that
the program's Housing Inspectors will conduct a
property inspection and prepare a work write-up
listing all substandard housing conditions.
•
The work write-up is reviewed with the owner. A
preliminary cost estimate is prepared and bids are
obtained from qualified General Contractors.
•
Once there is an accepted bid and contract amount,
the loan application is presented to the Board of
Chosen Freeholders for approval.
•
Upon approval by the Board, the loan documents are
prepared and a closing date is scheduled.
•
The owner then enters into an agreement with the
chosen contractor and work begins. Payments are
issued as the work progresses, after inspection
and approval by the Municipal Construction
Official (where applicable), program staff and upon
acceptance of the work by the owner.
Who will perform the work?
All work must be performed by insured contractors. It is 
the homeowner’s responsibility to select the contractor 
and enter into a contract for construction. Community 
Development Program staff are available to advise the 
owner regarding the review of contractors’ bids, the 
selection of contractors and specific construction contract 
terms.
HOME IMPROVEMENT LOAN PROGRAM  (609) 265-5072




--- Document: Construction Permit Application ---
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345678901234567890123456789012123456789012345678901234567890121234
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
12345
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
123
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
BLOCK _____________
LOT ______________ QUALIFICATION CODE _______________
ADDRESS (SITE) _________________________________
PERMIT NO. ______________________
CONSTRUCTION PERMIT
APPLICATION
Applicant Completes:  Sections I, II, III (optional), IV, VI, and VII
U.C.C. F100-1 (rev. 8/08)
V. FEE SUMMARY (for office use only)
$
1.
Number of Stories
VI. BUILDING/SITE CHARACTERISTICS
(office use only)
3.
Area — Largest Floor
sq. ft.
4.
New Building Area
sq. ft.
5.
Volume of New Structure
cu. ft.
ft.
2.
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. Construct. Classification:
1.
2.
3.
IV. DOES OR WILL YOUR BUILDING CONTAIN ANY OF THE FOLLOWING?
Update
Update
8.
Subtotal
$
10.
Subtotal
$
11.
Cert. of Occupancy
12.
Other
13. TOTAL
$
1.
Building
$
2. Electrical
3.
Plumbing
4.
Fire Protection
Elevator Devices
5.
6.
Subtotal
7.
Less 20% for State Plan Review
9.
State Permit Surcharge Fee
7. Max. Occupancy Load
6.
Max. Live Load
IIa.PROPOSED WORK
DO YOU WANT:
IIb. SUBCODES
(Check all that apply)
1.
Partial Releases
2.
Prototype Processing
III. PLAN REVIEW   (optional)
TOTAL COST
Plans
Rec'd by
Date
Rec'd
Rejection
Date
Approval
Date
Re-
viewer
 Resubmission Dates
    Approval              Rejection
Re-
viewer
Est. Cost
Minor Work                                               New Building                                Addition                             Demolition
Repair                                                       Alteration                                      Renovation                         Reconstruction
Asbestos Abat. -Subch. 8                         Lead Hazard Abatement               Radon Remediation            Annual Permit
8.
If Industrialized Building: State Approved
HUD
  9.
Total Land Area Disturbed
sq. ft.
10. Flood Hazard Zone
 11. Base Flood Elevation
ft.
 12. Wetlands
yes
no
Total Units Income-restricted
 Proposed
 Present
1.
Elevators/Escalators/Lifts/
Dumbwaiters/Moving Walks
2.
High Pressure Boilers
3.
Pressure Vessels
4.       Refrigeration Systems
5.       Cross-Connections/Backflow Preventers
6.       Hazardous Uses/Places of Assembly
7.       Sprinklers/Standpipes
8.      Smoke Control Systems in Open Wells
9.      Underground Storage Tanks
10.      Swimming Pools, Spas and Hot Tubs
11.      LPGas Tanks
12.     Fire Alarm
Building
Electrical
Plumbing
Fire Protection
Elevator
FOR OFFICE USE ONLY (Optional)
6. Responsible Person in Charge once Work has Begun
FAX:
Tel.
5. Architect or Engineer
Contact
FAX:
Address
Tel.
e-mail
License No. OR, if new home, Builder Reg. No.
Exp. Date
Home Improvement Contractor Registration No. or Exemption Reason 
Federal Emp. ID No.
FAX:
Private
Public
Ownership in Fee:
zip code
municipality
street
Address
Tel.
Principal Contractor:
4.
Address
e-mail
I.  IDENTIFICATION
Proposed Work Site at:
Name of Owner in Fee:
Tel.
e-mail
Select Group
Select Group
$0
Select Group
Select Group


CERTIFICATION IN LIEU OF OATH
I.
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 1.
Mark 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 family
residential use. I attest that all construction, plumbing, or electrical work will be done, in whole or in  part, by me or by
subcontractors under my supervision, in accordance with all applicable laws; and, I further acknowledge that said
new home is not covered under the New Home Warranty and Builders Registration Act (N.J.S.A. 46:3B-1 et seq.) and
that such fact shall be disclosed to any person purchasing this property within ten years of the date of issuance of a
certificate of occupancy.
I UNDERSTAND THAT IN MARKING BOX A, I ACKNOWLEDGE THAT I AM ASSUMING RESPONSIBILITY FOR
THE WORK DONE ON SAID PROPERTY, THE CONDITION OF THE PROPERTY PRIOR TO, DURING, AND AFTER
ANY WORK PERFORMED, AND FOR THE PERFORMANCE OF THE SUBCONTRACTORS I HIRE, EMPLOY, OR
OTHERWISE CONTRACT OR WITH WHOM I MAKE AGREEMENTS TO PERFORM WORK. I AM VOLUNTARILY
AND KNOWINGLY ASSUMING THIS RESPONSIBILITY.
B.
(
)
I further certify the following as required by the New Jersey Uniform Construction Code, N.J.A.C. 5:23-2.15(f)1.ix:
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 listed
on Page 1; or, 3) a new structure that will be physically separate from, but that will be deemed part of, an existing
single family residence that is owned and occupied by myself and located on the property listed on Page 1.
C.
(
)
I further certify that I will perform or supervise the following work:
C.1.
(
)
Building
C.2.
(
)
Fire Protection
I further certify that I will perform the following work:
C.3.
(
)
Electrical
C.4.
(
)
Plumbing
D.
(
)
I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of
Taxation and to comply with all New Jersey tax laws.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(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 given
prior to pemit issuance. 
I understand that if any of the above statements are willfully false, I am subject to punishment.
Signature_____________________________________________________________
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, N.J.A.C. 5:23-2.15(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 agent.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(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 given
prior to permit issuance. 
I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of Taxation
and to comply with all New Jersey tax laws.
I understand that if any of the above statements are willfully false, I am subject to punishment.
(
)
Check if contractor.
Agent Name _________________________________________________________________________________________
Address _____________________________________________________________________________________________
___________________________________________________________________________________________________
Telephone   ___________________________
Signature____________________________________________________________________________________________
III.
(
)
LEAD HAZARD ABATEMENT: Include Homeowner or Building Owner Affidavit as per N.J.A.C. 5:23-2.15(b)4.
IV.   (    )   HOME ELEVATION: Include Home Elevation Contractor Certification as per N.J.S.A. 52:27D-123.16.
U.C.C. F100-2 (rev. 11/2014)


1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678
LOCAL
APPROVAL
COUNTY
APPROVAL
REGIONAL
APPROVAL
STATE
APPROVAL
COMMENTS
Prelimin.
Initial
Prelimin.
Initial
Prelimin.
Initial
Prelimin.
Initial
Final
Date
Final
Date
Final
Date
Final
Date
OFFICE DATE RECEIVED: ______________________________
VIII.  PRIOR
APPROVALS
CHECKLIST
(office use only)
Zoning Officer
Planning Board
Zoning Board
Sewer Authority
Water Authority
Police Department
Health Department
Soil Conservation
N.J. Department of
Community Affairs
N.J. Department of
Transportation
N.J. Department of
Environmental Protection
Utility Dig No.
U.C.C. F100-3 (rev. 12/07)
IX. SUBCODES AND SPECIAL REGULATIONS APPLICABLE (office use only—optional)
Name of Code & Edition
Name of Code & Edition
Building ___________________________________________
Energy ____________________________________________
Other ______________________________________________
Electrical___________________________________________
Barrier Free ________________________________________
__________________________________________________
Plumbing __________________________________________
Flood Hazard _______________________________________
__________________________________________________
Fire Protection ______________________________________
As Built Elevation Cert. _______________________________
__________________________________________________
Mechanical _________________________________________
Other _____________________________________________
__________________________________________________
X. CERTIFICATES ISSUED (office use only)
DATE ISSUED
DATE EXPIRED
DATE REISSUED
DATE EXPIRED
Temporary Certificate of Occupancy
No. __________
___________________
___________________
__________________
___________________
Temporary Certificate of Compliance
No. __________
___________________
___________________
__________________
___________________
Continued Certificate of Occupancy
No. __________
___________________
___________________
__________________
___________________
Certificate of Compliance
No. __________
___________________
___________________
__________________
___________________
Certificate of Occupancy
No. __________
___________________
___________________
Certificate of Approval
No. __________
___________________
___________________
Lead Abatement Clearance Certificate
No. __________
___________________
___________________
__________________
___________________




--- Document: Building Subcode ---
BUILDING SUBCODE
BUILDING SUBCODE
BUILDING SUBCODE
BUILDING SUBCODE
BUILDING SUBCODE
TECHNICAL SECTION
TECHNICAL SECTION
TECHNICAL SECTION
TECHNICAL SECTION
TECHNICAL SECTION
Approved by:
Date:
[
]
CO
[
]
CCO
[
]
CA
SUBCODE APPROVAL
[   ] Elec.   [   ] Plumb.   [   ] Fire   [   ] Elevator
Joint Plan Review Required:
PLAN REVIEW
Date
Initial
INSPECTIONS
Dates (Month/Day)
JOB SUMMARY (Office Use Only)
JOB SUMMARY (Office Use Only)
JOB SUMMARY (Office Use Only)
JOB SUMMARY (Office Use Only)
JOB SUMMARY (Office Use Only)
A. IDENTIFICATION—APPLICANT:
A. IDENTIFICATION—APPLICANT:
A. IDENTIFICATION—APPLICANT:
A. IDENTIFICATION—APPLICANT:
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
U.C.C. F110 (rev. 08/05)
Internet version
C. CERTIFICATION IN LIEU OF OATH
C. CERTIFICATION IN LIEU OF OATH
C. CERTIFICATION IN LIEU OF OATH
C. CERTIFICATION IN LIEU OF OATH
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of
record and am authorized to make this application.
Signature
D.
D.
D.
D.
D. TECHNICAL SITE DATA
TECHNICAL SITE DATA
TECHNICAL SITE DATA
TECHNICAL SITE DATA
TECHNICAL SITE DATA
B. BUILDING CHARACTERISTICS
B. BUILDING CHARACTERISTICS
B. BUILDING CHARACTERISTICS
B. BUILDING CHARACTERISTICS
B. BUILDING CHARACTERISTICS
Constr. Class
Use Group
Present
Present
Proposed
Proposed
Est. Cost of Bldg. Work:
Est. Cost of Bldg. Work:
Est. Cost of Bldg. Work:
Est. Cost of Bldg. Work:
Est. Cost of Bldg. Work:
3.   Total (1+ 2)
$
2.  Rehabilitation
$
$
1.   New Bldg.
Total Land Area Disturbed
Volume of New Structure
New Bldg. Area/All Floors
Area — Largest Floor
Height of Structure
No. of Stories
Sq. Ft.
Cu. Ft.
Sq. Ft.
Sq. Ft.
Ft.
Date Received
Control #
Date Issued
Permit #
[
]
Other
[
]
Frame
[
]
Foundation
[
]
Footing
[
]
All
[
]
No Plans Required
Type:
Failure
Failure
Approval
Initial
Barrier-Free
Final
Other
TCO
Mechanical
Energy
Insulation
Barrier-Free
Truss Sys./Bracing
Frame
Slab
Foundation
Footing Bonding
Footing
Finishes -Base Layer
Finishes -Final
Applicant: When submitting this form to your Local Construction Code Enforcement
Office, please provide one original plus three photocopies.
Federal Emp. ID No.
zip code
municipality
street
Address
e-mail
Tel. (              )
Owner in Fee:
Contractor License No. or Builder Registration No.
Exp. Date
Contractor:
Tel.
(              )
Address
e-mail
FAX:
(              )
Block
Lot
Qualification Code
Work Site Location
DESCRIPTION OF WORK
TYPE OF WORK:
New Building
[    ]
Addition
[    ]
Rehabilitation
[    ]
Roofing
[    ]
[    ]
Siding
Fence ___________ Height (exceeds 6')
[    ]
Sign _____________ Sq. Ft.
[    ]
Pool
[    ]
Asbestos Abatement Subchapter 8
[    ]
Lead Haz. Abatement NJAC 5:17
[    ]
Other _______________________
[    ]
Demolition
[    ]
Radon Remediation
FEE (Office Use Only)
$
Administrative Surcharge
Minimum Fee
State Permit Surcharge Fee
TOTAL FEE
$
$
$
$
[    ]




--- Document: Electrical Subcode ---
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
D. TECHNICAL SITE DATA
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of record and am authorized to make this application and perform
the work listed on this application.
[  ] Licensed Elec. Contractor  [  ] Certif'd Landscape Irrigation Cont'r   [  ] Exempt Applicant
$
$
$
$
TOTAL FEE
Minimum Fee
Administrative Surcharge
State Permit Surcharge Fee
FEE (Office Use Only)
$
Temp. Cut-in-Card Date Issued
Final Cut-in-Card Date Issued
Annual Pool Inspection
Date of Grounding and Bonding
Certification
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
HP Garbage Disposal
HP/KW Space Heater/Air Handler
KW Central A/C Unit
KW Dishwasher
KW Elec. Dryer/Receptacle
KW Elec. Water Heater
KW Oven/Surface Unit
KW Elec. Range/Receptacle
Storable Pool/Spa/Hot Tub
Pool Permit/with UW Lights
TOTAL NUMBERS
Alarm Devices/F.A.C. Panel
Communications Points
Emergency & Exit Lights
Motors—Fract. HP
Light Poles
Detectors
Switches
Receptacles
Lighting Fixtures
ITEMS
SIZE
QTY.
KW Elec. Sign/Outline Light
AMP Motor Control Center
AMP Subpanels
AMP Service
KW Transformer/Generator
HP Motors 1/+ HP
KW Baseboard Heat
Federal Emp. ID No.
FAX:
(              )
Contractor:
Tel.
(              )
Address
e-mail
Exp. Date
Contractor License No.
Home Improvement Contractor Registration No. or Exemption Reason (if applicable):
Final
Service
Other
TCO
Constr. Serv.
Temp. Serv.
Rough
Initial
Approval
Failure
Failure
Type:
Dates (Month/Day)
INSPECTIONS
   Barrier-Free
Trench
   Barrier-Free
Initial
Date
Approved by:
Date:
Elevator
Fire
Plumbing
Building
Joint Plan Review Required:
[    ]
[    ]
[    ]
[    ]
[    ]
Elec. Plans Approved
No Plans Required
PLAN REVIEW
[    ]
Date:
CA
CCO
CO
SUBCODE APPROVAL
Approved by:
[    ]
[    ]
[    ]
JOB SUMMARY (Office Use Only)
Block
Lot
Qualification Code
Work Site Location
zip code
municipality
street
Address
e-mail
Tel. (              )
Owner in Fee:
B. ELECTRICAL CHARACTERISTICS
Use Group
Present
Proposed
Pole/Pad
Temporary
Other
[    ]
[    ]
[    ]
#
Building Occupied as
Est. Cost of Elec. Work $
Utility Co.
Applicant’s Signature/Contractor’s Seal and Signature
DESCRIPTION OF WORK
Applicant: When submitting this form to your Local Construction Code Enforcement Office, please provide one
original plus three photocopies.
U.C.C. F120 (rev. 10/06)
Internet version
ELECTRICAL SUBCODE
TECHNICAL SECTION
Date Received
Control #
Date Issued
Permit #




--- Document: Fire Subcode ---
US
NEW JERSEY
UNIFORM CONSTRUCTION
CODE
FIRE PROTECTION SUBCODE
TECHNICAL SECTION
A. IDENTIFICATION-APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
Block
Work Site Location
Owner in Fee:
Tel.(
)
Lot
e-mail
Qualification Code
Date Received
Control #
Date Issued
Permit #
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of record and am authorized
to make this application..
[ ] Certified Contractor
D. TECHNICAL SITE DATA
DESCRIPTION OF WORK:
Applicant's Signature/Contractor's Signature
[ ] Exempt Applicant
Address
street
Contractor:
Address
municipality
zip code
Tel. (
)
e-mail
Water Supply Source
Method of Alarm/Suppression System Supervision
Fire Protection Equipment, NJ Div of Fire Safety Permit No.
Fire Protection Equipment, NJ Div of Fire Safety Installer No.
Fire Alarm Contractor No.
Exp. Date
Home Improvement Contractor Registration No. or Exemption Reason (if applicable):
Federal Emp. ID No.
B. FIRE PROTECTION CHARACTERISTICS
FAX: (
)
Fuel Storage Tank:
Use Group: Present
Proposed
Flammable/Combustible Tanks
Alarm Systems
[ ] System
( ) 110v Interconnected
( ) CO Detectors/110v
Alarm Devices (i.e., smoke, heat, pulls,
water/flow)
Supervisory Devices (i.e., tampers, low/high air)
Constr. Class: Present
Proposed
Fuel Type: [ ] Flammable OR ( ) Combustible Signaling Devices (i.e., horn/strobes, bells)
Capacity
Other Devices
Heating System: ( ) New OR ( ) Modification to Existing
OR [ ] Conversion OR ( ) Replacement
Fire Alarm System: [ ] New OR [ ] Existing TOTAL
Location of Panel:
Suppression Systems
Fire Suppression/Standpipe System:
Fire Pump
GPM Type
Fuel Type:
(
[
) Gas ( ) Oil ( ) Electric [ ] Solar
] Other
[] New OR
[ ] Existing
Dry Pipe/Alarm Valves
Location of Main Control Valve:
NUMBER
FEE (Office Use Only)
Location:
Total Cost of Fire Protection Work $
JOB SUMMARY (Office Use Only)
PLAN REVIEW
[] No Plans Required
[ ] Partial-Underslab Utilities Approved
Date:
Approved by:
() Fire Protection Plans Approved
Date:
Approved by:
Joint Plan Review Required:
[ )Bldg. ( ) Elec. ( ) Plumb. [ ] Elev.
SUBCODE APPROVAL for PERMIT
Date:
Approved by:
SUBCODE APPROVAL for CERTIFICATE
[ ] CO [] CCO
Date:
Approved by:
U.C.C. F140 (rev. 12/07)
Internet version
INSPECTIONS
Dates (Month/Day)
Type:
Failure Failure
Approval Initial
Alarm System
Suppression Sys.
Standpipe
Fire Pump
Pre-Eng. System
Mechanical
Smoke Control
TCO
Flam/Combust Tanks
Fireplace Venting
[ ] CA
Final
Other
Reorder from OCS Printing 609-390-1400
Pre-action Valves
Sprinkler Heads (Dry and Wet)
Standpipes
Pre-engineered Systems
Wet Chemical
Dry Chemical
CO₂ Suppression
Foam Suppression
FM200 Suppression
Other
Other Systems
Kitchen Hood Exhaust System
Smoke Control System
Fuel-Fired Appliances ( ) Gas [] Oil [ ] Solid
Fireplace Venting/Metal Chimney
Other
Administrative Surcharge $
Minimum Fee $
State Permit Surcharge Fee $
TOTAL FEE $

--- Document: Mechanical Subcode ---
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
MECHANICAL INSPECTION
TECHNICAL SECTION
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
U.C.C. F145 (rev. 12/18) 
Internet version
FEE (Office Use Only)
TOTAL FEE
State Permit Surcharge Fee
Minimum Fee
Administrative Surcharge
Generator
Fireplace
LPG Tank
Oil Tank
Hot Air Furnace
Hot Water Boiler
Steam Boiler
Gas Piping Connections
Fuel Oil Piping Connections
Water Heater
FIXTURE/EQUIPMENT
NO.
$
$
$
$
Date Received
Control #
Date Issued
Permit #
Applicant: When submitting this form to your Local Construction Code
Enforcement Office, please provide one original plus three photocopies.
B. MECHANICAL CHARACTERISTICS
Estimated Cost of Mechanical Work    $
Fuel Type:
[    ]
[    ]
Hot Air
Hydronic
Type:
Use Group
R-3-or R-5
                       Present:
[    ] Other
[    ] Solar
Electric
[    ]
[    ] Oil
[    ] Gas
Heating System work:
Modification to Existing
New
Replacement
Conversion
[    ]
[    ]
OR
[    ]
OR
OR
[    ]
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
123456789012345678901234567890
121234567890123456789012345678
90121234567890
1234567890123456789012345678901
2123456789012345678901234567890
121234567890
678901
Failure
Failure
Approval
Initial
DATES
INSPECTIONS
Type:
Water Heater
Appliance
Chimney/Vent
Piping
Tank
Cooling/AC
Generator
Fireplace
Chimney Cert.
JOB SUMMARY (Office Use Only)
PLAN REVIEW
No Plans Required
[   ]
Mechanical Plans Approved
[   ]
Approved by:
Date:
SUBCODE APPROVAL for PERMIT
Approved by:
Date:
SUBCODE APPPROVAL for CERTIFICATE
CA
[    ]
12345 
[    ] CCO 
Other
234567890123456789012123456789012345678901234567890121234567890
Date:
Approved by:
Joint Plan Review Required:
[   ] Bldg.   [   ] Elec.   [   ] Plumb.   [   ] Fire.
[   ] Elev.
Contractor License No.
                    Exp. Date
Federal Emp. ID No.
FAX:             
Home Improvement Contractor Registration No. or Exemption Reason 
zip code
municipality
street
Address
e-mail
Tel. 
Owner in Fee:
Contractor:
Tel.
Address
e-mail
Block
Lot
Qualification Code
Work Site Location 
  
D. TECHNICAL SITE DATA
DESCRIPTION OF WORK
$
Other _________
Final                        ______     ______       _____      _____
_____             Other
I hereby certify that I am the (agent of) owner of record and am authorized to make this 
application. 
Applicant sign/Contractor 
sign and seal here:
C. CERTIFICATION IN LIEU OF OATH
         [    ] Licensed Contractor                          [    ] Exempt Applicant
Print name here:
R-5




--- Document: Plumbing Subcode ---
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
12345678901234567890123456789012123456789012345678901234567890121234567890
PLUMBING SUBCODE
TECHNICAL SECTION
B. PLUMBING CHARACTERISTICS
Date Received
Control #
Date Issued
Permit #
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
Block
Lot
Qualification Code
Work Site Location
zip code
municipality
street
Address
e-mail
Tel.            
Owner in Fee:
Exp. Date
Contractor License No.
Federal Emp. ID No.
FAX:             
Home Improvement Contractor Registration No. or Exemption Reason 
Sink
Floor Drain
Shower
Lavatory
Bath Tub
Urinal/Bidet
Water Closet
Backflow Preventer
Interceptor/Separator
Sewer Pump
Washing Machine
Hot Water Boiler
Steam Boiler
Gas Piping
Fuel Oil Piping
Water Heater
Hose Bibb
Drinking Fountain
Dishwasher
LPGas Tank
Greasetrap
U.C.C. F130 (rev. 11/09)
Internet version
Applicant: When submitting this form to your Local Construction Code
Enforcement Office, please provide one original plus three photocopies.
JOB SUMMARY (Office Use Only)
PLAN REVIEW
Joint Plan Review Required:
Approved by:
Date:
CA
[    ]
CO
SUBCODE APPROVAL for CERTIFICATE
[    ]
[    ] CCO
SUBCODE APPROVAL for PERMIT
Date:
Approved by:
[   ] Bldg.   [   ] Elec.   [   ] Fire.   [   ] Elev.
No Plans Required
[   ]
Plumbing Plans Approved
[   ]
Partial -Underslab Utilities Approved
[   ]
Approved by:
Date:
Approved by:
Date:
Est. Cost of Plumbing Work    $
Private Well
Public Water
Water Service Size
Private Septic
Public Sewer
Building Sewer Size
Proposed
Present
Use Group
Contractor:
Tel.             
Address
e-mail
Gas Piping
Gas Equipment
Sewer
Water
Rough
Slab
Type:
Dates (Month/Day)
INSPECTIONS
LPGas Tank
Fixtures
Initial
Approval
Failure
Failure
TCO
Solar
Fuel Oil Piping
Final
D. TECHNICAL SITE DATA
DESCRIPTION OF WORK
[    ]  Licensed Plumbing Contractor      [    ]  Exempt Applicant
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of record and am authorized to make this
application and perform the work listed on this application.
Print name here:
Applicant sign/Contractor
sign and seal here:
Stacks
Sewer Connection
Water Service Connection
Other
TOTAL FEE
State Permit Surcharge Fee
Minimum Fee
Administrative Surcharge
$
$
$
$
$
FIXTURE/EQUIPMENT
QTY.
FEE (Office Use Only)




--- Document: Chimney Certification ---
CHIMNEY VERIFICATION FOR
REPLACEMENT OF FUEL-FIRED EQUIPMENT
FOR MINOR AND EMERGENCY WORK, THIS FORM MUST BE PROVIDED WITH YOUR PERMIT APPLICA-
TION.  FOR ALL OTHER WORK, THIS FORM MUST BE PRESENTED TO THE CODE OFFICIAL PRIOR TO FINAL
INSPECTION.
All applicable information requested on this form must be supplied.
This form may not be submitted by a homeowner in lieu of the required inspection.
U.C.C. F370 (rev. 01/12)
Direct Vent Appliance:
I hereby verify that the appliance(s) being installed is a direct vent appliance. I further verify that the existing chimney/
vent is appropriately lined and sized for any remaining appliances.
Signature
Date
Verification Not Submitted:
I choose not to submit verification. I understand that I will be required to be present for the inspection to remove and
reinstall the chimney vent connector.
Signature
Date
Signature
Date
Oil to Oil or Gas to Gas Replacements or New/Additional Appliances:
I have verified that the existing chimney/vent is in good repair and clear of obstruction. I have verified that the existing
chimney/vent is appropriately lined and sized for the appliance(s) being installed and/or remaining.
For Oil or Coal to Gas Conversions:
I have verified that the chimney/vent is in good repair and clear of obstruction and is substantially clean of residue
from its previous use serving an oil or coal appliance. I have verified that the chimney/vent is appropriately lined and
sized for the appliance(s) being installed.
Signature
Date
PLEASE SIGN ONE OF THE FOLLOWING VERIFICATION STATEMENTS
Check the Appropriate Box(es):
Type of Replacement:
[
]
Oil to Gas Conversion
[
]
Gas Appliance Replacement
[
]
Oil to Oil Replacement
[
]
Other
[
]
Gas to Oil Conversion
Type
Fuel Type
BTU Rating (input/hour)
Appliance 1:
Appliance 2:
Appliance 3:
Oil / Gas / Other:
Oil / Gas / Other:
Oil / Gas / Other:
CHIMNEY LINER
If a chimney liner is being installed, all documentation on the liner must accompany the Permit application.
[
]
Other
[
]
Masonry Chimney-Tile Lined
[
]
Chimney-Interior
[
]
Chimney-Exterior
[
]
Masonry Chimney-Unlined
Existing Vent/Chimney:     Size
[
]
"B" Label Vent
[
]
"L" Label Vent
[
]
Flexible Liner
[
]
Power Vent/Exhauster
Manufacturer:                                               Model:                                                UL Listing:
Material of Liner:     Stainless Steel                                         Aluminum
Size of Appliance Vent:                                  Size of Liner:                                   Height of Chimney:
Length of Connector:                                      Vent Connector Rise:
How does the appliance vent?         [     ] Natural Draft        [     ] Fan-assisted       [     ] Other:
BLOCK                        LOT                         QUALIFICATION CODE                         PERMIT #
WORK SITE ADDRESS
Owner in Fee
Verifying Individual                                                       Company
Address
Street
City
State
Zip Code
Tel: (         )                                                                            Fax: (         )