ADDRESS TO BE INSPECTED*

BLACK JACK, MO 63033

OWNER/AGENT/OCCUPANT*

APPLICATION DATE*

OWNER/AGENT ADDRESS*

CITY, STATE & ZIP CODE*

EMAIL ADDRESS*

CONTACT NUMBER*

ADDITIONAL CONTACT INFORMATION

WILL ANY PART OF THE RESIDENCE BE USED TO RUN A BUSINESS? (IF YES A BUSINESS LICENSE IS REQUIRED)*

YES

NO

(CHECK ONE)*

OWNER RENTER SELLER BUYER

AGENT RE-OCCUPY NEW CONSTRUCTION

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(CHECK ONE)HOUSE TO BE:*

BOUGHT SOLD

LEASED/RENTED INHERITED

*If the building is on septic, a full septic report is needed before the scheduled inspection date.*

*SEPTIC

SEWER (MSD)

PROPOSED DATE OF OCCUPANCY*

PLEASE READ THE FOLLOWING: FIRST INSPECTION FEE IS $125.00. THE SECOND INSPECTION FEE IS $30.00. THIRD AND FOURTH INSPECTIONS ARE $50.00 EACH. MISSED INSPECTION FEE IS $50. ACCEPTED FORMS OF PAYMENT ARE MONEY ORDER, CASHIER’S CHECK OR CREDIT CARD (ADDITIONAL USER FEE IS ASSESSED FOR CARD TRANSACTIONS), NO PERSONAL OR COMPANY CHECKS ARE ACCEPTED. ALL INSPECTION FEES ARE NON-REFUNDABLE. IF THE INSPECTION FAILS FOUR TIMES, A $125.00 FEE AND NEW APPLICATION ARE REQUIRED. CANCELLATIONS REQUIRE A 24 HOUR NOTICE. TO CANCEL, CONTACT THE PERMIT CLERK AT 314-355-7406 OR LEAVE A VOICE MESSAGE. FAILURE TO DO SO WILL RESULT IN A FAILED INSPECTION AND AN ADDITIONAL $50.00 MISSED INSPECTION FEE. ALL UTILITIES (GAS, ELECTRIC & WATER) MUST BE TURNED ON AT THE TIME OF INSPECTION. INSPECTION APPLICATIONS ARE VALID FOR SIX MONTHS FROM DATE OF SUBMISSION AND PAYMENT. BY SIGNING BELOW, YOU AGREE TO THE ABOVE TERMS AND CONDITIONS.

SIGNATURE OF APPLICANT*

FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS AREA

INSPECTION DATE

INSPECTION TIME

ADDRESS TO BE INSPECTED*