Your Name

Your Email

Phone Number

APPLICATION FOR GAS PERMIT

Date

BUILDING PERMIT

OWNER/BUILDER

SITE ADDRESS

GAS CONTRACTOR

CONTRACTOR MAILING ADDRESS

Type of Building: (please indicate number of units)

Residential Units

Commercial Units

Other units

Please mark the following with an "X":

Addition
Check Box Addition

New
Check Box New

Alteration
Check Box Alteration

Repair
Check Box Repair

NATURAL GAS OPENINGS
FIRST FIVE (5) GAS OPENINGS .................................... 50.00

THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 6 MONTHS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 6 MONTHS AT ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION ANO 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 ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION.

EST VALUATION

AR CONT LICENSE #

EXP DATE

MASTER LICENCE

EXP DATE_2

Signature: Please type your name below as your signature.

This information is subject to release under Arkansas' freedom of information legislation.