PERMIT INFORMATION® Permittee and Complete Address: _______________________________________________________  _____________________________________ Permitee’s Contact Name: ______________________ Title / Phone / Email: ________________________________________________________________ Employer Identification #:________________ Phone: _________________ Fax: _______________ Property owner and Complete Address: __________________________________________________ ______________________________________ Owner’s Contact Name: _______________________ Title / Phone / Email: ________________________________________________________________ Employer Identification #:______________ Phone: _________________ Fax: _________________ Project Name: ______________________ ____ Parcel#: ____________________ Acreage: _______ Project Address: ___________________________________________________________________ Project Description: _________________________________________________________________ Project estimated start date: ___________________ Project estimated completion date: _____________ Onsite Supervisor/Title: _______________________________________________________________ Phone and Email: ___________________________________________________________________ Dust Class Certification #: ____________________________ Expiration Date: ___________________ Is the onsite supervisor responsible for dust control  YES or NO ?  And the SWPPP  YES  or  NO  ?  Water Source (circle): water truck - hydrant - jones valve – stand tank – pond – well – other _____________ Will there be offsite work? Y / N If yes, what is the approved plan # for offsite work: __________________ Please include a copy of the soil report and a set of mini plans (10X17), for the preparation of the SWPPP. Project Description: Include demolition (size, year built square footage of buildings), owners designee (name, address and phone) blasting, crushing and a DESCRIPTION OF WORK TO BE PERFORMED ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Revised 07/10