COMMERCIAL BUILDING PERMIT APPLICATION
CITY OF ASH FLAT 
Contractor License Number- ________             
911 Address (If you don’t have this, please call 870-994-2211 to obtain the address)
Lot/Sect	   Block/Twp                                                          Addition/Range
Owner	           Mailing Address	Phone #
Contractor
Use of Building
Class of Work:		New		Addition		Alteration		Repair
Description of Work: ____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
NOTICE: All Work Must Be In 		Valuation        Plan Check   Shingle Deposit    Act 474
Accordance with Ordinance 2005-4-1         	  of Work            Fee              Check No.        Surcharge
and Ordinance 2-1-2000.
_________________________________$_________  $__________  #________  $___________
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 BESTOW THE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY STATE OR LOCAL LAWS REGULATING CONSTRUCTION OR THE PERFORMANCE OF ANY AND/OR ALL CONSTRUCTION	
	
CIRCLE ONE:  County:  SHARP    or   FULTON

                  __________________________________________
                                                                          Permit Number When Issued/Issued By
NOTICE TO CONTRACTOR/BUILDER: Contractor/Builder will dispose of all waste material from the construction site to a State licensed and Environmental Protection Agency (EPA) approved landfill. Contractor will furnish a receipt from the landfill to Ash Flat City Hall as evidence of compliance. Failure to comply with this disposal requirement may result in revocation of Building Permit, and/or fines as per Ordinance 98-9-1. My initials indicate that I have read & will comply with this notice.           ___________        ____________                           
                                                                                                                                    Initials                      Date

SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT	DATE

SIGNATURE OF OWNER, (IF OWNER IS BUILDER)	DATE