2. Property Address:*
4. Owner*
5. Phone Number *
7. Description of work to be performed *
9. Is the work associated with the new placement of a mobile/manufactured home?*
   -- Select One --YesNo
11. Contractor *
12. Phone Number: *
14. Address*
16. Item(s)*

    1. Ceiling Fans
    2. Central HVAC
    3. Elevator
    4. Exhaust Fans
    5. Meter Loop (Specify Size)
    6. Motor (Specify Size)
    7. Outlet/Fixtures/Switches

    1. Pole Lighting
    2. Range/Dryer/Water Heater Receptacle
    3. Signs
    4. Smoke Detectors
    5. Transformers (Specify KVA)
    6. T-pole
    7. Misc.
18. Total Square Footage:
19. Total Valuation:*
21. Quantity *
    Please provide the quantity for each of the selected items above.
23. I hereby certify that the Statements on this application are true to the best of my knowledge and belief. I further certify that I, as Applicant, agree to work in accordance with the City of Dickinson Code of Ordinances and other governing codes and agree that no work will be started on the property prior to securing a permit. Knowingly making a false entry on a governmental record is a felony of the 3rd Degree in accordance with Section 37.10(a)(1) of the Texas Penal Code.
25. License Number *
26. Date *
28. Personal Installation by an owner under the homeowner's rights shall be by himself, for himself, on his own homestead premises and no person shall be employed to assist him in any way on such work.
30. Are you the Homeowner?*
    -- Select One --Yes No
31. By selecting yes you understand the above statement and do hereby certify that you are the homeowner, residing in the home, and accept full responsibility for the above described work.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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