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2. Part 1: Information about the requestor
4. First Name*
5. Last Name*
7. Mailing Address*
9. City
10. State
11. Zip Code
13. Email Address*
14. Phone Number
18. Information about the subject property and its proposed use
20. Street Address or Location of the Subject Property
22. City
23. State
24. Zip Code
26. The Legal Description of the Subject Property

    The Subdivision, Square, and Lot(s) are MANDATORY fields.  Please enter "N/A" if it does not apply.  The legal description of the property can be obtained by contacting the Jefferson Parish Assessor's Office at 504-362-4100.

28. Subdivision*
29. Square*
30. Lot(s)*
32. Detailed Description of the Proposed Use:*
34. Will you be storing any materials on site?*

    1. Yes
    2. No
36. If you answered yes to the above question please check all that apply

    1. Cement, lime, gypsum or plaster of paris manufacture or storage
    2. Fuel gas storage (not service stations or gas stations)
    3. Fuel gas distribution station
    4. Gasoline storage and wholesale distribution (Does not include service stations or gas stations)
    5. Gas manufacture
    6. Gravel pits
    7. Land and gravel storage yard
    8. Oil, gas and mineral exploration
    9. Refining of petroleum or its products
    10. Sand and gravel pits
    11. Sand blasting as a primary occupation
    12. The production and/or storage of red label chemicals and products as defined by the Occupational Safety and Health Administration (OSHA)
    13. Vulcanizing and galvanizing shops
    14. Any other similar use which would by objectionable or obnoxious because of danger from radiation, explosion or because the emission or creation of smoke, dust, fumes, odors, gas, noise, vibration or similar conditions
    15. Other (Specify below)
38. Specify other materials indicated above
42. 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.
44. Electronic Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field