Revised 01/06/21
Planning and Development Department
Building Code
2725 Judge Fran Jamieson Way
Building A, Room 114
Viera, Florida 32940
(321) 633-2187 Phone
Building Permit Number
Site Address
_____________________________ _______________________ ________ ____________
Street City State Zip Code
I certify that the manufactured home to be installed at the above referenced address is safe for
Home Manufacturer
Year Built
I-Beam Spread (if width of mobile home is 12 feet or more)
Federal Wind Zones from Mobile Home Data Plate: III (South Florida) II (South)
In the event the manufactured home is determined to be unfit for human occupancy when
inspected by the Brevard County Building Code Inspector, the manufactured home must be
removed from the property within five days. Failure to remove the home will result in
appropriate Code Enforcement or other legal action by the County against the property owner,
mobile home park, and /or the mobile home installer.
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Revised January 6, 2021
__________________________________________ __________________
Printed name of Manufactured Home Installer License Number
__________________________________________ __________________
Signature of Manufactured Home Installer 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 Seal