1
Gas Permit Application
Date: Permit #: Job Cost:
Address__________________________________________________________________________________
Subdivi
sion________________________________________________Lot______
___________________
Owner / Occupant________________________
Address__
______________________________
City__
____________State_____Zip__________
Gas Fitter_______________________________
Address__
______________________________
City__
___________State_______Zip_________
_________________________________________________________________________________
* * * * SIGNATURES * * * *
By signing this application, I hereby certify that all information herein is true and correct, and I agree to be personally
responsible to the City of Irondale for any and all code violations and code enforcement associated with this gas
application and the installation contemplated herein, whether such actions or inactions were performed by me, my
company, employees, contractors or sub-contractors.
Name (Print):______________________________Signature_______________________________________
Signature of Authorized Master Gas Fitter_____________________________________
Master Gas Fitter Certificate______________________________
Date:____________
Date:____________
* State Craft Fee: If job is commercial, add $1.00 per $1,000 of the job cost
*