Loading...
Gas Permit App fill-in2016.10.19 File Number:________________ Date Received:_______________ Tax Roll No.: ____________ GAS PERMIT APPLICATION FORM Development Permit No.: Estimated Project Completion Date (mmm/ddd/yyyy): ________________________________ Permit Applicant:  Owner Contractor Work has not started  Work is in progress  Work is complete Owner / Applicant: _____________________________________________________ Mailing Address: City: Province: Postal Code: Phone: Cell: Email: Fax: Contractor: Mailing Address: City: Province: Postal Code: Phone: Contractor Name: Cell: Email: Fax: Project Location: Municipality: County of Newell Subdivision Name: Street/Rural Address: Postal Code: Lot: Block: Plan: Legal Subdivision: Section: Township: Range: West of: Directions: Please Provide a Detailed Description of Work: TYPE OF OCCUPANCY TYPE OF WORK NUMBER OF OUTLETS Single Residential New  Renovation  Addition Furnaces: Farm/Ranch Single Family Dwelling Water Heaters: Other:Manufactured/Mobile Home Boilers: ____________________Service Reconnection Fireplaces: Accessory Building Dryers: _____________________ Temporary Heat: ___________ units Unit Heaters: Project Total BTU (excluding residential and farm): BBQs: ____________________________________ Ranges: Secondary Gas Line: Other: _________________________ Other: Total: FOIPP Notification: The personal information required by the County of Newell application forms is collected under the authority of section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act and section 63 of the Safety Codes Act. It will be used for processing permit applications, issuing permits, safety codes compliance monitor ing and verification. The name of the permit holder and nature of the permit may be included on reports provided to the municipality or made available to the public as required or allowed by legislation. Please direct any questions about this ollection to the County of Newell at 403-362-3266 or 183037 Range Road 145, PO Box 130, Brooks, AB T1R 1B2. Journeyman’s Name (print) Journeyman’s Signature Homeowner ‘s Signature (homeowner permit only) Homeowner Declaration: By signing this application I hereby certify that I own/will own and occupy this dwelling. Journeyman’s Certification No.: Office Use Only Permit Fee: $ SCC Levy: Issuing Officer’s Name: Total Cost: $ ($4.50 or 4% of the permit fee maximum $560.00) Issuing Officer’s Signature: Receipt No.: Designation No.: Cash  Debit  Cheque Permit Issue Date (mmm/dd/yyyy): 183037 Range Road 145 P.O. Box 130 Brooks, AB T1R 1B2 Phone: 403-362-3266 | Fax: 888-361-7921 | www.countyofnewell.ab.ca