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2. Job Address*
4. Registered landmark or in historic distric?*

   1. Yes
   2. No
5. Choose one*
   -- Select One --ResidentialCommercial
7. Describe scope of work*
11. Property Owner*
13. Address*
15. City*
16. State*
17. Zip*
19. Phone Number*
21. Residential

    1. Owner Occupied
    2. Rental Property
22. Tenant name (if commercial)
26. Developer
28. Contact Name
30. Address
32. Phone Number
36. Firm Preparing Plans
38. Contact Name
40. Address
42. Phone Number
46. Registered Architect or Engineer
48. Illinois Registration Number
52. General Contractor
54. Contact Name
56. Address
58. Phone Number
62. Sprinkler Contractor
64. Address
66. Phone Number
70. Roofing Contractor
72. Address
74. State Roofing License Number
75. Expiration Date
77. Phone Number
81. Electircal Contractor
83. Address
87. Mechanical Contractor
89. Address
93. Plumbing Contractor
95. Address
99. Valuation
    Labor and materials for all contractors involved.
101. Building
102. Demolition
104. Sprinkler
105. Sign
107. Electrical
108. Mechanical
110. Plumbing
111. Sidewalk
113. Approach/Curb Cut
115. Total Job Cost*
119. Under penalty of intentional misrepresentation and/or perjury, I declare that I have examined and/or made this application and it is true and correct to the best of my knowledge and belief. I agree to construct said improvement in compliance with the Moline Code of Ordinances. I realize that the information I have affirmed hereon forms a basis for the issuance of the building permit herein applied for and approval of plans in connection therewith shall not be construed to permit any construction upon said premises or use thereof in violation of any provisions of any City of Moline Ordinance or to excuse the owner or his successors in title from complying therewith. The applicant agrees that THIS STRUCTURE SHALL NOT BE USED, OCCUPIED OR FURNISHED IN WHOLE OR IN PART UNTIL A CERTIFICATE OF OCCUPANCY IS ISSUED as required by law.
121. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
123. Electronic Signature*
125. Address*
127. City*
128. State*
129. Zip*
131. Phone Number*
132. Email Address*
134. Attention
     Thank you for submitting your online application. Once the application has been reviewed we will contact you for payment and issue the permit. Work cannot begin until the permit has been issued.
Leave This Blank:


136. 1. Receive an email copy of this form.
137. Email address

     This field is not part of the form submission.

138. Submit

* indicates a required field