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COMMUNITY AND DEVELOPMENT SERVICES APPLICATION FOR RESIDENTIAL BUILDING PERMIT PEMBROKE KY

Application Date:*
MM slash DD slash YYYY
Zoning:*
OWNER INFORMATION
Last Name:*
First Name:*
Phone*
Address*
Street Address City State ZIP Code
BUILDING DETAIL
Choose Building Type*
- New Residential
- Duplex
- Residential Addition
Accessory Structures:
- Detached Garage
- Storage Building
- Detached Carport
- Above Ground Swimming Pool
- In Ground Swimming Pool
Construction Plan Designated*
Size of Structure*
Building Area (Sq. Ft.)*
Stories*
Height of Structure*
Total Building Cost: Material & Labor*
ELECTRICAL DETAIL
Any extensions or modifications to wiring system?*
- Yes
- No
(Any extensions or modifications require an electric permit and inspection by a State Electrical Inspector)
Service*
- New
- Change
- Extension
Size Amp
PROPERTY INFORMATION
Address*
Street Address ZIP Code
Subdivision*
Lot #*
Parcel #*
Is any part of the property located in the Flood Plain?*
- Yes
- No
If yes, what zone?
Will the structure obstruct natural drainage?*
- Yes
- No
Are there sinkholes or other obstructions on site?*
- Yes
- No
Have all utility and drainage easements onsite been designated on the Site Plan?*
- Yes
- No
Has a proper sized entrance tile (minimum 15") been installed at the entrances to the property or is curb and gutter being used?*
- Tile
- Curb & Gutter
LOT DETAIL
Interior Lot*
Corner Lot*
Front Yard Setback off Property Line*
Feet (Consider Right of Way)
Rear Yard Setback off Property Line*
Feet
Left Yard Setback off Property Line*
Feet
Right Yard Setback off Property Line*
Feet
Lot Width at Publicly Maintained Street*
Feet
Lot Width at Building Setback*
Feet
Existing structures on property?*
- Yes
- No
Type
Size of Structure
Sq. Ft.
EASEMENT WIDTH
Utility:
Front Yard*
Ft.
Right Side Yard*
Ft.
Left Side Yard*
Ft.
Rear Yard*
Ft.
Drainage:
Front Yard*
Ft.
Right Side Yard*
Ft.
Left Side Yard*
Ft.
Rear Yard*
Ft.
Sketch project showing streets, property lines and lot dimensions, existing and proposed structures, setback distances and all utility and drainage easements.
Or upload your sketch
Accepted file types: pdf, jpg, gif, png, Max. file size: 16 MB.
The above information is true and correct to my best knowledge and belief.
Signature*
Date*
MM slash DD slash YYYY
SUBCONTRACTORS TO BE EMPLOYED ON THIS PROJECT
General Contractor Name or Firm
General Contractor Address
Street Address Address Line 2 City State ZIP Code
General Contractor Phone
General Contractor License #
Electrical Contractor Name or Firm
Electrical Contractor Address
Street Address Address Line 2 City State ZIP Code
Electrical Contractor Phone
Electrical Contractor License #
Plumbing Contractor Name or Firm
Plumbing Contractor Address
Street Address Address Line 2 City State ZIP Code
Plumbing Contractor Phone
Plumbing Contractor License #
Heating/Cooling Contractor Name or Firm
Heating/Cooling Contractor Address
Street Address Address Line 2 City State ZIP Code
Heating/Cooling Contractor Phone
Heating/Cooling Contractor License #
Framing Contractor Name or Firm
Framing Contractor Address
Street Address Address Line 2 City State ZIP Code
Framing Contractor Phone
Framing Contractor License #
Masonry Contractor Name or Firm
Masonry Contractor Address
Street Address Address Line 2 City State ZIP Code
Masonry Contractor Phone
Masonry Contractor License #
Siding Contractor Name or Firm
Siding Contractor Address
Street Address Address Line 2 City State ZIP Code
Siding Contractor Phone
Siding Contractor License #
Finish & Trim Contractor Name or Firm
Finish & Trim Contractor Address
Street Address Address Line 2 City State ZIP Code
Finish & Trim Contractor Phone
Finish & Trim Contractor License #
Roofing Contractor Name or Firm
Roofing Contractor Address
Street Address Address Line 2 City State ZIP Code
Roofing Contractor Phone
Roofing Contractor License #
Drywall Contractor Name or Firm
Drywall Contractor Address
Street Address Address Line 2 City State ZIP Code
Drywall Contractor Phone
Drywall Contractor License #
Painting Contractor Name or Firm
Painting Contractor Address
Street Address Address Line 2 City State ZIP Code
Painting Contractor Phone
Painting Contractor License #
Excavation Contractor Name or Firm
Excavation Contractor Address
Street Address Address Line 2 City State ZIP Code
Excavation Contractor Phone
Excavation Contractor License #
Other Contractor Name or Firm
Other Contractor Address
Street Address Address Line 2 City State ZIP Code
Other Contractor Phone
Other Contractor License #
I hereby certify that I understand that all contractors and subcontractors to be employed on this project must have a current business license issued by the City of Pembroke and are in compliance with Kentucky Law regarding to Workers Compensation and Unemployment Insurance.
Applicant’s Signature
Date
MM slash DD slash YYYY
I hereby certify that all work on this project will be performed by the homeowner and no additional workers will be employed.
Applicant’s Signature
Date
MM slash DD slash YYYY
CERTIFICATION

In consideration of the issuance of the requested permit, I hereby agree and covenant, with the City of Pembroke, the Hopkinsville-Christian County Planning Commission, that I will observe and conform with all applicable codes, zoning ordinances, and all other applicable codes, laws, restrictions and ordinances, and I hereby assume all risk incidental to any error or any violations or interpretations thereof.

The Property Owner and Contractor hereby release the City of Pembroke, the Hopkinsville-Christian County Planning Commission and their employees from all liability of every kind and nature for damages which may occur from defective wiring or construction of or on said premises and hereby agrees to hold harmless the City of Pembroke, the Hopkinsville-Christian County Planning Commission and their employees from any kind and all such liabilities.

I hereby certify that I understand the contents of the above paragraphs and that information used to complete this application is true and correct to my best knowledge and belief. I am the owner of record of the named property, or that the proposed work is authorized by the owner of record and that I have been authorized by said owner to make this application as his authorized agent.
Applicant’s Signature*
Date*
MM slash DD slash YYYY
Permit Fee*
Price:
Permit Fee*
Price: $0.00
Total
$0.00
Name
This field is for validation purposes and should be left unchanged.

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Fax:
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