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.