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PERMIT INFORMATION® Fax -702-398-7412 Permittee: _________________________________________________________________________________ Contact Name / Title / Phone / Email: ___________________________________________________________ Complete Address: __________________________________________________________________________ Employer Identification #:___________________Phone: ____________________Fax: ___________________ Property owner: ____________________________________________________________________________ Complete Address: __________________________________________________________________________ Employer Identification #:___________________Phone: ____________________Fax: ___________________ Owners Contact: Name and Title: ______________________________________________________________ Phone and Email: ___________________________________________________________________________ Project Name: _________________________________Parcel#: _______________________Acreage: _______ Project Description: _________________________________________________________________________ Project estimated start date: ____________________Project estimated completion date: ___________________ Authorized Signatory for SWPPP (Manager or above): _____________________________________________ Onsite Supervisor/Title: ______________________________________________________________________ Phone and Email: __________________________________________________________________________ Dust Class Certification #: ___________________________________Expiration Date: ___________________ Is the onsite supervisor responsible for dust control _______________? And the SWPPP ________________? 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 |