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Planning & Development Department
2725 Judge Fran Jamieson Way
Building A, Room 114
Viera, Florida 32940
(321) 633-2187 Phone
Building Permit Number/
Special Event Permit Number/
Code Enforcement Case Number
Site Address
________________________________ _________________________ ________ ____________
Street City State Zip Code
I hereby certify that the business operating at the above address is considered a small business in accordance
with Title 13 Part 121 of the Electronic Code of Federal Regulations OR employs less than 500 employees. The
United States Small Business Administration (SBA) provides a tool to assist with this determination and is
available at
I understand that being considered a small business may qualify an applicant/respondent for reduced or
waived repair permit fees, waived special event permit fees, elimination of code enforcement fines after
compliance is achieved and enforcement costs paid, and/or abatement of code enforcement efforts for non-
health/safety issues in accordance with action taken by the Brevard Board of County Commissioners on April
7, 2020. These relief mechanisms apply to small businesses only and expire on September 1, 2020 at 11:59
I understand that if I knowingly make a false declaration herein, I could be found guilty of the crime of perjury
by false written declaration, a felony of the third degree, which is punishable as provided in Sections 775.082,
775.083, or 775.084, Florida Statutes.
Signature of Business Owner/Officer/Registered Agent Date
___________________________________________ ___________________________
Subscribed and sworn to before me, by _____ physical presence or _____ online notarization, this _____
day of _______________, 20 ______, personally appeared _____________________________________
who is personally known to me or produced _________________________________________ as
identification, and who did/did not take an oath.
Notary Public Signature