T:\BLD\Bldg_Forms\New Applications\Applications\Building Permit Application.Docx Rev. 11/10/15
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION
Designer/Architect/Engineer:
Not Applicable
Name ______________________________________
Mailing Address ______________________________
City ____________________________ State ______
Zip __________ Phone ________________________
Mortgage Company:
Not Applicable
Name ______________________________________
Mailing Address _____________________________
City ____________________________ State ______
Zip __________ Phone ________________________
Fee Simple Title Holder’s Name:
Not Applicable
Name ______________________________________
Mailing Address ______________________________
City ____________________________ State ______
Zip __________ Phone ________________________
Bonding Company:
Not Applicable
Name ______________________________________
Mailing Address _____________________________
City ____________________________ State ______
Zip __________ Phone ________________________
Notice to Owner: There are some properties that may have deed restrictions recorded upon them. These
restrictions may limit or prohibit the work applied for in your building permit. It may be to your
advantage t
o check and see if your property is encumbered by any restrictions.
Owner/Cont
ractor Affidavit: 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.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the
work in
accordance with the approved plans, the Florida Building Code 5th Edition (2014) and Martin County
Amendments. Plan revisions on all structures exempted by code from architect/engineer design may be done by
permit holder.
Warn
ing 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
commencing work or recording your Notice of Commencement.
I c
ertify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
(FBC 5th Edition 2014)
____________________________________
Signature of Contractor/License Holder
STATE OF
FLORIDA
COUNTY OF MARTIN
The foregoing instrument was acknowledged before me
this ______ day of ______________, 20___ by
__________________________________________
(Name of Person Acknowledging)
_____________________________________________
(Signature of Notary Public – State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary
Public)
Personally Known ____ OR Produced Identification ____
Type of Identification Produced
________________________________________
Signature of Contractor/License Holder
STATE OF FLORIDA
COUNTY OF MARTIN
The foregoing instrument was acknowledged before me
this ______ day of ______________, 20___ by
__________________________________________________
(Name of Person Acknowledging)
___
_______________________________________________
(Signature of Notary Public – State of Florida)
(Prin
t, Type, or Stamp Commissioned Name of Notary Public)
Per
sonally Known _____ OR Produced Identification _______
Type of Identification Produced ________________________
________________________________________
Signature of Owner/Agent/Lessee
STATE OF FLORIDA
COUNTY OF MARTIN
The foregoing instrument was acknowledged before me
this ______ day of ______________, 20___ by
___________________________________________________
(Name of Person Acknowledging)
___
________________________________________________
(Signature of Notary Public – State of Florida)
(Pr
int, Type, or Stamp Commissioned Name of Notary Public)
Per
sonally Known _____ OR Produced Identification _______
Type of Identification Produced ______
___________________
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