Town of Amherst Mechanical Permit Application

Property Owner Name*

First NameLast Name
Job Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contractor Name:*
Type Contractor Name or Type Homeowner
Contractor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contractor E-mail
example@example.com
Contractor Phone Number

Area CodePhone Number
Scope of work
Date of Installation:

MonthDayYear
Date
Residential or Commercial

ResidentialCommercial
Residential

New or Replace Heating EquipmentNew AC equipment (per unit)Replace AC equipmentReplace AC equipment (per unit)Other (Call for fees)
Commercial

New or Replace Heating EquipmentNew AC equipment (per unit)Replace AC equipmentReplace AC equipment (per unit)Other (Call for fees)
Location of AC unit. Ex. Side yard, rear yard, front yard....
Estimated Value of the Work:
Description of Proposed Work:
I, the undersigned property owner or authorized agent of the owner, am familiar with the requirements of the Workers Compensation Law and declare that (check the following):

I have filed the required proof as affirmed by my insurance carrier.I have no people working directly for me and therefore require no Workers Compensation Insurance. Should there be any change in my status during the exercise of this permit, I will so advise the Building Department and comply with all requirements.
In consideration of granting this permit, the undersigned property owner or authorized agent of the owner hereby agrees to comply with the terms thereof, the Laws of the State of New York, the Ordinances of the Town of Amherst and the regulations of the various departments of the Town, County of Erie and the State of New York, request all necessary inspections and authorize and provide a means of entry to the premises for the Inspector. Furthermore, the undersigned property owner or authorized agent of the owner has read and will comply with these conditions. The undersigned property owner or authorized agent of the owner hereby certifies that all of the information in this petition is true and correct.
Permit Signature (Sign using your mouse)

Clear
Should be Empty:

Scope of work