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r <br />. ?,,,?,?sT Boardvf Building Standards <br />? ? 6606 Tussing Road, P.O. Box 4009 <br />? Reynoldsburg, OH 43068-9009 <br />(614) 6442613 Fas (614) 644-3147 Fa4Back (614) 72& 1244 <br />APPLICATION ? ? ? <br />'rTAtE pi ? dic.bbs@com.state.oh.us <br />OUD TTL TO A TTlIAT -.. . www.com.state.ohus/diddicbbs.htm <br />r.l1n mrtT _ <br />PVA lIIr, Vlil\111'1LC111V11 Vt' A 1. BUILDINGDEPARTMENT: <br />RESIDENTTAL BITILDING <br /> Deept. Name: <br />DEPARTMENT - FORM A <br /> street: <br />Pursuant to section 3781 <br />10(A) of the Ohio R <br />i <br />d City: <br />. <br />ev <br />se <br />Code and rules adopted by the Board of Building Zip Code: <br />Standards, this application is being submitted for Telephone No: <br />certification of a residential building department to <br />accept construction documents and to exercise Faac No: <br /> <br />enforcement authority in accordance with the Date: year:2p <br />Residential Code of Ohio. E-mail Address: <br /> <br />2. BUILDING DEPARTMENT CERTIFICATION: Yes No <br />Is the Residential Bldg. Dept. certification being requested as a part of the If "Yes" give the nonresidential Bldg. Dept. <br />enforcement authority of a certified nonresidential building department? 11 El Number (from Appndx. Z): <br />3. BUILDING DEPARTMENT INFORMATION: <br />Is this application per contract certification with Yes No If "Yes", give name of the Certified Residential Bldg. Dept. <br />another Certified Residential Bldg <br />Dept <br />? ?? under contract <br />. <br />. <br />. <br />Appropriated Operating Budget: $ For Fiscal Year: To: <br />Jurisdiction Area Population at Last Date Building <br />In Sauare Miles: Census: Dent_ Established: 20 <br />4. DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION* (indicate enclosure with an "X" in the appmpriate box): <br />? Ordinance/Resolution Creating Res. Building Department ? Inspection and Plan Examination Procedures <br />? Ordinance/Resolution Requesting Res. Cettification ? List of Primary and Backup Positions Directly Employed as <br />Required for Enforcement Pursuant to 4101:&1-03 OAC. <br />? <br />Res. Depart ment Organizational Chart <br />ADDTTIOIVAL DOCiJMENTATION FOR CERTIFICATION OF CONTRACT PERSONNEL: <br />If Not Directly Employed, ConUact/Agreement for. ? Res. Bldg. Official(s) ? Res. Plan Exam.(s) ? Res. Bldg. Inspector(s) <br />? Electrical Safety Inspector(s) r-I Res. Plmbg. Inspector(s) <br />. <br />. <br />. . <br />.. ....__......._--° ............................................... <br />•DOCUMENTS TO BE SUBMITTID FOR CFRTIFICAITON PER CONTRACT ONLY: <br />? Ordinance/Resolution Creating Residential Building Depazlment ? Ordinance/I2esolution Requesting Res. Certification <br />? Qrdinance/Resolution Authorizing Contract F-I Copy of Contract <br /> <br />5. SIGNATLJRES OF APPROPRIATE AUTHORIT'IES (Municipal Officials, County Gommissioners, or Township Ttustees): <br />Name TiUe Date <br />Name Title Date <br />Name TiUe Date <br />Name Titk Date <br />507021 <br />EXHIBIT <br />I