uniform permit application for office use only building … · uniform permit application –...
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D.E.R.D #: ___________________ Permit Type: ________________________________ Permit No: _________________________________
Uniform Permit Application – Building Department Page 1 of 2 02/01/2014
FOR OFFICE USE ONLY
UNIFORM PERMIT APPLICATION Building Department
401 NW 70 Terrace Plantation, FL 33317
Ph: 954-797-2714 Fax: 954-797-2273
Contractor Registration Fax: 954-797-2270
Inspection Line: 954-587-4456 ext. 5000
Online Services: www.velocityhall.com
FOR OFFICE USE ONLY
Kind of Permit (Check one): Master Permit Sub Permit – Master Permit# ________________________
Trade (Check one): Structural Electrical Mechanical Plumbing Engineering Other: _______________________
Permit Holder: Contractor Owner Builder (per FL Statutes 489) – see box above for contact information.
Company Name: _______________________________________________ Qualifier’s Name: ______________________________
Mailing Address: ____________________________________________________________
City: ___________________________________ State: _______ Zip: ______________
Phone: ( ______ ) ______ - ___________ Fax: ( ______ ) ______ - ___________ Email: _________________________________
Property Owner: ____________________________________________________________
Mailing Address (if different from job address): _________________________________________________________
City: ___________________________________ State: _______ Zip: ______________
Phone: ( ______ ) ______ - ___________ Fax: ( ______ ) ______ - ___________ Email: _________________________________
Project Information
Job Address: _______________________________________________________ Folio #: _______________________________
Legal Description: ___________________________________________________________________________________________
Residential Non-Residential || Interior Exterior || Square Ft: _________ Lineal Ft: __________
Type of Work: New Addition Alteration/Completion Demo Repair Roofing Other: _________________________
Type of Construction: _____________ Occupancy Group: ____________ Occupant Load: ____________
Tenant: _______________________________________________ FBC/NEC Edition: _________________________________
Description/Scope of Work: ____________________________________________________________________________________
__________________________________________________________________________________________________________
Total Contract Cost: $_______________________
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS, etc. OWNER’S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning.
____________________________________________________________ Signature of Owner or Authorized Representative (Circle One)
____________________________________________________________ Owner or Auth. Representative’s Name & Title, if not Owner (Please Print)
_____________________________________________________________ Signature and Stamp of Notary Public, State of Florida
Sworn to (or affirmed) and subscribed before me this _________ day of
_______________________________________________, 20______, by
_____________________________________________________, who is
personally known to me or has produced _______________________
as identification. Did Take an Oath Did Not Take an Oath
______________________________________________________________ Signature of Contractor – Qualifier or Agent (Circle One)
______________________________________________________________ Qualifier or Agent’s Name (Please Print)
State Registration #: _____________________________________________
State Cert./Cert. of Competency #: __________________________________
______________________________________________________________ Signature and Stamp of Notary Public, State of Florida
Sworn to (or affirmed) and subscribed before me this _________ day of
_______________________________________________, 20______, by
_____________________________________________________, who is
personally known to me or has produced _______________________
as identification. Did Take an Oath Did Not Take an Oath
Permit Fee: $ ___________________________ Permit No: __________________________________
Uniform Permit Application – Building Department Page 2 of 2 02/01/2014
Architect/Engineer’s Name: ____________________________________________________________________________________
Architect/Engineer’s Address: __________________________________________________________________________________
Bonding Company: __________________________________________________________________________________________
Bonding Company Address: ___________________________________________________________________________________
Fee Simple Titleholder’s Name (If other than owner): ________________________________________________________________
Fee Simple Titleholder’s Address (If other than owner): ______________________________________________________________
Mortgage Lender’s Name: _____________________________________________________________________________________
Mortgage Lender’s Address: ___________________________________________________________________________________
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION.
IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
IMPORTANT: Give notice for Inspections as per Florida Building Code 110.4 and 110.5; All approved plans, permit card and specifications MUST be on the job when an inspection is made; and Permit shall expire as per Florida Building Code 105.11.2.1 if construction is not begun or suspended. NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management districts, state agencies or federal agencies. All city streets, sidewalks and curb damaged due to the construction shall be repaired to the satisfaction of the Public Works Department prior to issuing the Certificate of Occupancy. City properties on which earth spills or other debris falls shall be cleaned immediately. The owner of the building and the undersigned agree to conform to all applicable laws of this jurisdiction.
FOR OFFICE USE ONLY BELOW THIS SECTION
DEPARTMENT APPROVED BY DATE DEPARTMENT APPROVED BY DATE
ZONING FIRE
STRUCTURAL LANDSCAPE
ELECTRICAL ENGINEERING
MECHANICAL UTILITIES
PLUMBING
Application Approval: ________________________________________________ Date: _____________________
* This Permit does not become valid until signed by the Building Official or an Authorized Representative.
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