RESIDENTIAL ELECTRICAL JOB LOCATION Job Address: City: Zip: Municipality:
Job Between What Roads? Side of Road Job is On
Contractor Name: Licensee: DOB/DL #:
Address: City: Zip: Phone: Fax:
State Lic # Fed ID # MESC#
Workman's Carrier: Contractor's Email:
Homeowner Name Phone: Fax:
Address: City: Zip: DOB/Dr.L #
Section 23a of the State Construction Code Act of 1972, Act No. 230 of the Public Acts of 1972, being Section 125, 1523a of the Michigan Compiled Laws, prohibits a person from conspiring to circumvent the licensing requirements of this state relating to persons who are to perform work on a residential building or a residential structure. Violators of Section 23a are subject to civil fines. HOMEOWNERS AFFIDAVIT: I hereby certify the work described on this permit application shall be installed by me, by myself in my own home,in which I am living or about to occupy. All work shall be installed in accordance with the State Code and shall not be enclosed, covered up or put into operation until it has been inspected and approved by the inspector. I will cooperate with the inspector and assume the responsibility to arrange for the necessary inspections. By entering your name, you electronically acknowledge that you have read and accept this permit application. Contractor/Homeowner Signature: Application Date:
JOB INFORMATION- Fill in all the appropriate information for your job below.
2 Insp.-Rough/Final or Service/Final $162.00 3 Insp.- Service, Rough & Final $243.00
(Plus enter items to be installed below at no extra charge.) FOR ANY OTHER WORK AND REMODELING JOBS-BASE FEE OF $81.00 (Plus add cost of items to be installed)
ENTER NUMBER OF ITEMS TO BE INSTALLED BELOW
Service- New, Temp or Upgrade *Plus $23.00 Each* Plus $9.00 Each* for the items to be installed below
Circuits 110v Air Conditioning Light Fixtures Security Motion Detectors 220v Circuits Security Alarms/Horns Meter/Well Hookup Generator Circuit Furnace/Heater Kitchen Appliances Control Panel for Home Security Systems LOW VOLTAGE: Up to 10 Jacks $9.00- Over 10 Jacks $19.00 Cable TV Phone Computer
Code Compliance Inspection-Additional-Reinspection $81.00 Yearly License Administartive Fee $15.00 Installation started without permit being obtained $100.00 Administrative Fee TOTAL DUE: Make Checks payable to C.C.A. or Construction Code Authority For Credit Card Payments, Contact C.C.A. 810-667-0420 Surcharge Fee of 3.5 % will be applied for Credit Cards.