Fillable BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING (Broward County)

Fill Online, Printable, Fillable, Blank BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING (Broward County) Form

Use Fill to complete blank online BROWARD COUNTY (FLORIDA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING (Broward County)

On average this form takes 67 minutes to complete

The BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING (Broward County) form is 32 pages long and contains:

  • 2 signatures
  • 13 check-boxes
  • 255 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Broward County (Florida) forms online.

BROWSE BROWARD COUNTY (FLORIDA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 1 of 20
ALL DOCUMENTS MUST BE STAMPED WITH THE PRIVATE PROVIDER’S
LOGO PRIOR TO BEING SUBMITTED TO THE BUILDING DEPARTMENT.
THE APPLICATION STARTS ON PAGE 2. PLEASE SCROLL DOWN.
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 2 of 20
Alternate Plans Reviews and Inspections Requirements
Florida Statute 553.791
FLORIDA STATUTE 553.791 (15)(B) AUTHORIZES THE BUILDING OFFICIAL TO ADOPT A SYSTEM OF REGISTRATION.
General Information:
The use of a Private Provider is authorized by Florida Statute 553.791 under “Alternate Plans Reviews and Inspections”.
Unincorporated Broward County Building Code Services Division "BCS" requires that only the forms in this packet be used (no
substitutions will be accepted, unless authorized by the State of Florida Building Commission or The Broward County, Board of Rules and
Appeals) for the application process. All forms must be fully completed prior to the acceptance of the application for any permit.
Note 1: Applications for permit by a Private Provider will not be accepted until approvals and permits are issued by all outside
agencies known by the Building Official per the Florida Building Code, Broward County Administrative Provisions, section
105.2.3.
Note 2: All Private Provider Firms must be registered with BCS prior to the application permit submittal.
Note 3: If you have any questions, please contact the Building Official by email rpuentes@broward.org for detailed
registration requirements.
Documentation is to be submitted for evaluation by BCS. Original documents should be presented in a three-ring binder to the
Building Official.
1. Letter of Acceptance from Private Provider stating the services provided to fee owner (Private Provider shall not be the
Designer or Engineer of Record, the Duly Authorized Representative, or the Contractor for the project per FS 553.791(3).
2. Private Provider registration
3. Employment affidavit for Duly Authorized Representatives (DAR)
4. Private Provider Agreement
5. DBPR Certificate of Authorization for the firm.
6. A copy of the Professional Licenses for each of the DAR personnel regulated by Florida Statutes chapter 481 (Architects),
chapter 471 (engineers), and chapter 486, Part XII (Building Code Administrators and Inspectors).
7. Certificate of professional liability insurance as required by FS 553.791(16) naming Broward County Building Code Services
Division as Certificate Holder.
8. A Blank Original of the actual inspection report form to be used on the project for inspection by the DAR. Normally this would
be a three or a four-part form (white on top with a yellow, pink, and blue copy).
9. Private Provider’s list of requested inspections (All trades), on a private provider letterhead, shall be signed and sealed by the
Private Provider and signed by the Duly Authorized Representative (DAR), and shall be notarized.
10. Private Provider shall submit the signed and sealed construction drawings accompanied by the “Plan Compliance Affidavit” as
required by FS 553.791(6).
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 3 of 20
To be submitted with the initial permit application:
1.
Notice to Building Official.
This is the principal document required for the official election to use a Private Provider and will specify if the Private Provider
will perform the services of inspections only or whether the services will include plans reviews and inspections. This
document must be accompanied by the Personnel Directory and Qualifications Statement and the certificate of insurance.
Note: If a Private Provider performs the plans reviews, the Private Provider shall also perform the required
inspections.
2.
Personnel Directory & Qualifications Statement.
This document identifies all the Private Providers Duly Authorized Representatives (DAR) utilized on the specific project. It
shall contain the numbers of the current licenses they hold to perform their specified type of work on the project, their
contact phone number, email address, the responsibility that the DAR will have for the specific project, a Qualification
Statement, and a current resume for each DAR. This form is filled out for each of the DAR’s of the Private Provider. This form is
for the Building Official to keep as reference. Another similar form (Private Provider Jobsite Identification Form) will be kept at
the job site. Every DAR (Inspector or Plans Examiner) shall be certified by the State of Florida.
3.
Certificate of Insurance.
This certificate is provided by the Private Provider Insurance Carrier and must be submitted with each permit application. It is
also submitted at the time of the initial registration with BCS. It must show coverage in the statutory amounts pursuant to F.S.
553.791(16) and must include Broward County Building Code Services Division as the certificate holder.
The following shall be submitted as a PREREQUISITE with the building permit application, if Private Provider performs plans review:
4.
Plan Compliance Affidavit.
This form is required, after the Private Provider has performed the required plan reviews and has approved those plans for
code compliance under the scope allowed by F.S. 553.791(6). (This form will not be required for jobs where the Private
Provider is to perform Inspections only).
Note: The Building Official may require, at his or her discretion, the private provider to be used for both services (Plans
Review and Jobsite Inspections) pursuant to Section 553.791(2)(a) Florida Statute.
The following is required Jobsite documentation:
1.
Private Provider Job Site Identification Form
This is to identify each individual Duly Authorized Representative (DAR) involved. Forms must be provided when the plans are
submitted so they can be perforated/stamped and returned to the jobsite. Form(s) for each DAR shall be kept on the jobsite in
a log and shall be updated and kept current by the Private Provider. Building Code Services may perform periodic jobsite visits
at their discretion per FS 553.791(9). Form entries will be compared to inspections reports. Any new entries to the worksite
log will need to be approved first by the Building Official. The inspection reports shall be submitted to the Building Official
every two days, in accordance with FS 553.791(10) and at the final inspection. Inspection reports must only be written by
those previously approved inspectors.
Note: The Building Official or designee may visit the building site as often as necessary to verify that the “Private Provider” is
performing all required inspections pursuant to Section 553.791(9) Florida Statute.
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 4 of 20
2.
Inspection Reports.
The Private Provider shall submit to the Building Official for approval prior to the start of the project, a blank copy off the
form that will be supplied to the DAR for recording and logging the inspections.
The inspection reports must provide:
•
The date the inspection was performed.
•
The permit number for the inspection
•
The job address.
•
The project name.
•
The Private Providers company contact information.
•
The Inspectors name, license number, & signature
•
The inspection comments (including location/area of the inspection)
•
The inspection results (Approved, Partial Approval, or Rejected)
•
The corrections required (if corrections or further action is required).
Requirements prior to approval for Certificate of Completion or Certificate of Occupancy
1.
Official Log for all Completed Inspections.
The official log will include all inspections reports performed by each Duly Authorized Representative (DAR), and must be
organized by discipline (Building, Mechanical, Electrical, Electrical Low Voltage, Plumbing, Roofing, etc.), and included whether
the inspection was approved or rejected. The log will also include the “Private Provider Job Site Identification Form” for all
inspectors and any additional closing documents that pertain to the job.
•
If requesting a TCO (at the direction of the Building Official):
•
An inspection report with pending items for final approval listed for each permitted trade.
•
Inspections reports or approval letter from BSO Fire Marshal’s Office indicating each floor or all floors approved
(Florida Building Code, Broward County Administrative Provisions section 111.3).
•
E Final Approval, Zoning Sign Off, SWM Approval
•
If requesting a Certificate of Completion:
•
The final inspection report for each trade, and all outside agencies approvals per the FBC, Broward County
Administrative Provisions section 111.1.
•
If there are threshold or specialty inspections performed:
•
threshold inspection reports
•
Final Threshold and building envelope Completion/Acceptance letter for the structure from the threshold
Engineer.
•
Threshold Inspection Final Approval Letter from the Private Provider
•
Inspection Reports from special inspectors
•
Shoring and reshoring reports
•
Welders Certifications
•
Specialty Inspector Inspection Final Approval Letter from specialty Engineer
•
Acceptance for the Specialty Inspections Final Letter from the Private Provider
•
Affidavit for TCO/CO from private provider for each trade.
2.
Certificate of Compliance from the Private Provider.
This form shall be provided by the Private Provider and shall be signed, sealed & dated by the Professional in Charge of the
Duly Authorized Representatives (DAR) as outlined in F.F. 553.791(11). The inspections that are required to be performed per
Code requirements and per Official Construction Documents shall be affirmed by the designated Professional in Charge for the
Private Provider Company.
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 5 of 20
PRIVATE PROVIDER STIPULATION
Permit # Address of Project:
Private Provider Firm:
Authorized Representative for Private Provider Firm:
Print Name and Title
or
Individual Private Provider:
Telephone: ( ) _- Email:
Florida License, Registration or Certification #:
I, in my capacity as the Individual Private Provider (IPP) or authorized representative of the Private Provider Firm (PPF) for the above
referenced Project do hereby agree to the following conditions:
1.
Prior to submittal to Unincorporated Broward County Building Code Services Division (City), all construction plans and documents
(Construction Documents) for the above-referenced Permit shall be pre-approved by me insofar as each page shall bear my initials
(IPP) or stamp (PPF).
2.
No Duly Authorized Representative (DAR) that perform inspections of the Project shall allow any work to start or continue which the
IPP or the PPF has not reviewed and pre-approved under the above-referenced Permit in accordance with the Construction
Documents approved by the City for the Project.
3.
Any and all revisions to the Construction Documents must be submitted to, and approved by, the IPP or the PPF and are subject to
audit by the City’s plan reviewers for that portion of the Project.
4.
Depending on the severity of the violation and at the discretion of the City’s Building Official, if the IPP or PPF fails to comply with the
preceding conditions and/or other applicable laws, regulations, and codes attendant to the Project, the IPP or PPF shall be placed on
notice and a Stop Work Order issued on any non-compliant portion of the Project in accordance with The Florida Building Code,
Chapter I, Broward County Administrative Provisions, Section 115.
Note: If you are signing this as an Authorized Representative for a PPF, the attached Certificate of Incumbency must be completed and
accompany submittal of this Private Provider Stipulation.
INDIVIDUAL
CORPORATION
PARTNERSHIP
c
(Print Corporation Name)
(Print Partnership Name)
(Signature)
(Signature)
(Signature)
(Name)
(Name)
(Name)
(Address)
(Address)
(Address)
(Telephone Number)
(Telephone Number)
(Telephone Number)
STATE OF COUNTY OF
Please use appropriate notary section below:
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 6 of 20
Before me, this day of , 20
personally appeared
who executed the foregoing instrument, and
acknowledged before me that same was executed
for the purposes thein expressed.
Before me, this day of , 20
personally appeared
of
, a
corporation, on behalf
of the state corporation, who executed the
foregoing instrument, acknowledged before me
that same was
executed for the purposes thein expressed.
Before me, this day of , 20 _
personally appeared
,
partner/agent on behalf
of
, a partnership, who executed the foregoing
instrument, acknowledged before me that same
was
executed for the purposes thein expressed.
(NOTARY’S SIGNATURE)
Notary Name
(Print, Type or Stamp Notary’s Name)
Personally Known _ or Produced Identification _
Type of Identification Produced
NOTARY
STAMP
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 7 of 20
PRIVATE PROVIDER STIPULATION
CERTIFICATE OF INCUMBENCY
STATE OF _
COUNTY OF _
The undersigned, , in my capacity as an
Print Name
Officer, Director, Manager or Partner (circle one) of _
Print Name of Company
(the “Company”), a corporation, limited liability company
Print Name of State
or partnership (circle one) and pursuant to its By-Laws, as amended, and certain validly adopted
resolution(s) hereby certifies as follows:
The Company is authorized to serve as a Private Provider in accordance with §553.791, Florida Statutes, for the
construction project located at in For a r al, Florida.
(the “Project”).
has been designated to serve as the Authorized Representative
for the Company and given authority to act on behalf of and to bind the Company in its capacity as a Private Provider
for the Project.
The undersigned has the power and authority to execute this Certificate on behalf of the Company and has so
executed same and set the Company seal this day of , 20 .
Signature: _
Print Name: _
Title:
SEAL
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 8 of 20
NOTICE TO BUILDING OFFICIAL
OF USE OF PRIVATE PROVIDER
Project Name / Address:
Permit/Process number:
Project address: Parcel tax ID:
Services to be provided (select one): □ Inspections only □ Plans Review and Inspections
I, , the fee owner of the property referenced above, hereby affirm that I
have entered into a contract with the Private Provider firm identified below to conduct the services indicated above.
Private Provider Firm:
Private Provider (Qualifier for the Firm):
Florida License or Registration number:
Address:
Telephone: Fax: Email:
I understand if I, the fee owner, or the fee owner’s contractor elects to use a private provider to provide plans review, the local
building official, in his or her discretion and pursuant to duly adopted policies of the local enforcement agency, may require the fee
owner or the fee owner’s contractor to use a private provider to also provide required building inspections, F.S. 553.791(2).
I have elected to use one or more private providers to provide building code plans review and/or inspection services on the building or
structure that is the subject of the enclosed permit application, as authorized by s. 553.791, Florida Statutes. I understand that the
local building official may not review the plans submitted or perform the required building inspections to determine compliance with
the applicable codes, except to the extent specified in said law.
Instead, plans review and/or required building inspections will be performed by licensed or certified personnel identified in the
application. The law requires minimum insurance requirements for such personnel, but I understand that I may require more
insurance to protect my interests. By executing this form, I acknowledge that I have made inquiry regarding the competence of the
licensed or certified personnel and the level of their insurance and am satisfied that my interests are adequately protected. I agree to
indemnify, defend, and hold harmless the local government, the local building official, and their building code enforcement personnel
from any and all claims arising from my use of these licensed or certified personnel to perform building code inspection services with
respect to the building or structure that is the subject of the enclosed permit application, F.S. 553.791(4)(c).
Note: Building plans review and/or inspection services provided by the private provider is limited to building code compliance and
does not include review for fire code, land use, environmental, FEMA regulations or other applicable codes. I understand that the local
building code enforcement agency may audit the performance of building code plan review and inspection services performed by
private providers operating within the local jurisdiction, F.S. 553.791(18).
If I, the fee owner, or the fee owner’s contractor makes any changes to the listed private providers or the services to be provided by
those private providers, I, the fee owner, or the fee owner’s contractor shall, within 1 business day after any change, update the
notice to reflect such changes. A change of a duly authorized representative named in the permit application does not require a
revision of the permit, and the building code enforcement agency shall not charge a fee for making the change. In addition, I, the fee
owner, or the fee owner’s contractor shall post at the project site, prior to the commencement of construction and updated within 1
business day after any change, on a form to be adopted by the AHJ, the name, firm, address, telephone number, and facsimile
number of each private provider who is performing or will perform building code inspection services, F.S. 553.791(4)(c).
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 9 of 20
□ □
In accordance with F.S. 553.791 the following attachments are provide as required:
1.
Qualification statements, resume, and a copy of the private provider license required by F.S. 471 or F.S. 481 and all duly
authorized representatives’ employment affidavits are signed, and notarized & copies of all licenses required by F.S. 468.
2.
Private Provider Plan Compliance Affidavit is signed and notarized unless Private Provider is only performing building
inspections for project.
3.
Private Provider complete list of requested building inspections, (all trades) in accordance with FBC_BCA 110.3.
4.
Section 553.791(16) of the Florida Statutes provides for requiring minimum insurance coverage for professional liability
covering all services performed as a private provider. The section states: “A private provider may perform building code
inspection services on a building project under this section only if the private provider maintains insurance for professional
liability covering all services performed as a private provider. Such insurance shall have minimum policy limits of $1 million
per occurrence and $2 million in the aggregate for any project with a construction cost of $5 million or less and $2 million per
occurrence and $4 million in the aggregate for any project with a construction cost of over $5 million. Nothing in this section
limits the ability of a fee owner to require additional insurance or higher policy limits. For these purposes, the term
“construction cost” means the total cost of building construction as stated in the building permit application. If the private
provider chooses to secure claims-made coverage to fulfill this requirement, the private provider must also maintain
coverage for a minimum of 5 years subsequent to the performance of building code inspection services.
Individual: By: (signature) Print name:
Address: _Telephone:
STATE OF COUNTY OF Before me, this _day of_ ,20 _, personally
appeared , who executed the foregoing instrument, and acknowledged
before me that same was executed for the purposes therein expressed.
Personally known □ or Produced Identification □ Type of ID produced:
Signature of Notary: , Print Name _
Notary public stamp: My commission expires:
Corporation: Print Corporation Name: _
By: (signature) Print name: Its:
Address: Telephone:
STATE OF COUNTY OF _Before me, this day of _, 20 ,
personally appeared, _ _on behalf of the stated corporation, who executed the
foregoing instrument, and acknowledged before me that same was executed for the purposes therein expressed.
Personally, known or Produced Identification Type of ID produced:
Signature of Notary: Notary Stamp:
Print Name
Partnership: Print Partnership Name: _
By: _(signature) P r i n t name: Its:
Address: _Telephone: _
STATE OF _COUNTY OF
personally appeared,
executed the foregoing instrument, a
therein expressed.
Personally known □ or Produced I
Signature of Agent
_Before me, this _day of, ,20 ,
partner/agent on behalf of the partnership, who
a
nd acknowledged before me that same was executed for the purposes
dentification □ Type of ID produced: _
F.S. 553.791(19) I understand that the local government, the local
building official, and their building code enforcement personnel shall be
immune from liability to any person or party for any action or inaction
by a fee owner of a building, or by a private provider or its duly
authorized representative, in connection with building code plan review.
click to sign
signature
click to edit
click to sign
signature
click to edit
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 10 of 20
PRIVATE PROVIDER JOB
SITE DIRECTORY
Florida Statute §553.791(4) requires that this form be posted at the job site
for all projects involving Private Providers for plan review or inspections.
Permit Number: - Project Name:
Project Address:
Property Folio No.:
Owners Name:
Private Provider or Duly Authorized Representative (DAR):
Email:
Telephone:
Fax:
State of Florida Professional License(s):
Private Provider Company:
Private Provider / Address:
Type of Service Provided:
Insurance Policy:
Private Provider or Duly Authorized Representative (DAR):
Email:
Telephone:
Fax:
State of Florida Professional License(s):
Private Provider Company:
Private Provider / Address:
Type of Service Provided:
Insurance Policy:
Private Provider or Duly Authorized Representative (DAR):
Email:
Telephone:
Fax:
State of Florida Professional License(s):
Private Provider Company:
Private Provider / Address:
Type of Service Provided:
Insurance Policy:
Private Provider or Duly Authorized Representative (DAR):
Email:
Telephone:
Fax:
State of Florida Professional License(s):
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 11 of 20
Private Provider Company:
Private Provider / Address:
Type of Service Provided:
Insurance Policy:
Note: If additional space is needed additional copies of this form must be attached.
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 12 of 20
PRIVATE PROVIDER
PERSONNEL IDENTIFICATION
& QUALIFICATION
STATEMENT
PRIVATE PROVIDER PERSONNEL IDENTIFICATION & QUALIFICATION STATEMENT
Florida Statutes § 553 791(4)
Please use a separate page for each Private Provider Duly Authorized Representative (DAR).
Project Name:
Project Address:
Permit Number:
Duly Authorized Representative (DAR) Name:
Type of Service/(s) to be performed by this DAR (plan review, inspections or both and what TRADE):
DAR Email address:
Telephone:
Fax:
State of Florida professional licenses:
Private Provider Company Name:
Address:
Qualifications Statement (or attach resume to this form):
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 13 of 20
EMPLOYMENT AFFIDAVIT
For Private Provider Duly Authorized Representatives (DAR), as per F S §553.791(4)(b)
Florida Statute 553.791(8) requires that all Duly Authorized Representative(s) be employees of the Private Provider who is/are
entitled to receive unemployment benefits under Chapter 443 of the Florida Statutes.
I, _, the Private Provider, do hereby affirm that the Duly Authorized
Representative(s) listed below are my employee(s), as required by Florida Statute 553.791 and are entitled to receive
unemployment compensation benefits under Chapter 443.
DULY AUTHORIZED REPRESENTATIVES:
If more space is needed to list all DAR, have another separate “Employment Affidavit Form” signed and sealed, to list them.
Name
State of Florida
License(s) #:
Discipline
Signature
BORA Certified
Yes
No
Submit resumes of each Duly Authorized Representative and copies of their licenses.
Private Provider Company Name:
X
Signature of Agent
STATE OF
COUNTY OF
Authorized Agent for Private Provider Company (Print Name):
Sworn to (or affirmed) and subscribed before me this day of
, 20 by:
Authorized Agent for Private Provider Company (Title):
(Type / Print Agent Name)
(NOTARY’S SIGNATURE as to Agent)
Notary Name
(Print, Type or Stamp Notary’s Name)
Personally Known _ or Produced Identification _
Type of Identification Produced:
NOTARY SEAL
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 14 of 20
PRIVATE PROVIDER PLAN COMPLIANCE AFFIDAVIT
Florida Statutes §553.791(6)
Project Name / Address:
Plan number: Folio number:
Construction Documents □ Revisions □ Shop Drawings □ As-Built □ Other □
If “other” is marked, please clarify: ________________________________________________________
______________________
Master permit number:
Private Provider Firm:
Private Provider Address:
Telephone: Fax:
Email:
I HEREBY CERTIFY that to the best of my knowledge and belief, the documents submitted for
the above referenced project was reviewed according to, and are in compliance with, the Florida.
Building Code and all local amendments thereto, either by myself or by the affiant identified below, who
is duly authorized to perform plans review pursuant to Section 553.791, Florida Statutes, and holds the
appropriate license or certificate:
Private Provider:
Florida License No.
Seal/Signature/Date
Name of person reviewing the plans (if applicable):
Florida License/Registration/Certification numbers:
Discipline and Plan Sheets covered by this affidavit:
Signature of reviewer: Date:
SWORN AND SUBSCRIBED before me by , being personally known
to me () or having produced as identification , and who being fully
sworn and cautioned, states that the foregoing is true and correct to the best of his/her knowledge and
belief.
Signature of Notary: Print Name: Date:
Notary Public: NOTARY PUBLIC STAMP BELOW My Commission Expires:
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 15 of 20
PRIVATE PROVIDER REGISTRATION
Florida Statutes §553.791(15)(b)
Please submit all the following documents. Certificate of Insurance must be sent directly from your
insurance company to the U nincorporated Broward County, only, Building Code Services Division.
1. Copy of current Florida license for the business entity (Certificate of Authorization).
2. Copy of Florida licenses for all Private Providers.
3. Resume for Qualifier and all Private Providers.
4. Business Tax Receipt registration.
5. Copy of Driver’s License.
6. Certificate of Insurance for General Liability and Worker’s Compensation. The Certificate must
name Broward County Building Code Services Division as the certificate holder, in accordance
with FS 553.791(16).
PRIVATE PROVIDER FIRM
Name of Firm:
Business Address:
Telephone:
Fax:
Email:
Federal Employer Identification Number (FEIN):
PRIVATE PROVIDER (QUALIFIER):
Name of Qualifier:
Home Address:
Home Telephone:
Alternate Telephone:
X _
Signature of Qualifier
STATE OF _
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of
, 20 _ by:
(Type / Print Qualifier Name)
(NOTARY’S SIGNATURE as to Qualifier)
Notary Name
(Print, Type or Stamp Notary’s Name)
Personally Known _ or Produced Identification _
Type of Identification Produced
NOTARY SEAL
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 16 of 20
FIRE-RATED JOINT AND PENETRATION(S) AFFIDAVIT
Permit No:
Project Name:
Project Address:
I, _, the qualifying agent for the company noted below, HEREBY CERTIFY that all
penetrations through walls, ceilings, floors and other barriers resulting from the passage of pipes, conduits, bus ducts, cables, wires,
air ducts, pneumatic ducts and penetrations from similar building service equipment installed in connection with the above permit
have been protected by approved fire rated materials or assemblies meeting the acceptance criteria of AMERICAN SOCIETY FOR
TESTING AND MATERIALS (ASTM) E814, or UNDERWRITERS’ LABORATORIES (UL) 1479, or other approved testing standard, and have
been installed by qualified persons in accordance with the manufacturer’s specifications, and are in compliance with the Florida
Building Code and approved Plans.
I FURTHER CERTIFY that all joints installed in or between fire-resistance rated walls, floor or floor/ceiling assemblies and roofs or
roof/ceiling assemblies have been protected by an approved fire-resistant joint system meeting the acceptance criteria of ASTM
E1966, or UL 2079, or other approved testing standard.
Print Name
Title
Signature
Date
Company
Telephone
Email
WITNESS:
Print Name
Signature
WITNESS:
Print Name
Signature
STATE OF
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of
, 20 by:
(NOTARY’S SIGNATURE)
Notary Name
(Print, Type or Stamp Notary’s Name)
Personally Known _ or Produced Identification _
Type of Identification Produced:
NOTARY SEAL
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 17 of 20
PRIVATE PROVIDERS PERFORMING INSPECTIONS ON BUILDING PERMITS
Inspection process:
1. Private Providers performing inspections must schedule all inspections PRIOR to performing them, using
either the automated phone line or online portal, as noted in the permit package for City Inspections.
2. Results are to be emailed or faxed to the Broward County Building Code Services Division, within two
business days and may be accompanied by photographic evidence of the inspection performed. Exclusion
of the images may trigger an audit of the project.
3. Staff will monitor these emails for Private Provider inspection results and process them accordingly.
Inspection results emailed where inspections were not requested first will not be accepted and may trigger an
audit of the project.
Acknowledged By:
(Signature)
(Print Name)
(Date)
(Signature)
(Print Name)
(Date)
(Signature)
(Print Name)
(Date)
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 18 of 20
GENERAL CONTRACTOR
SPOT SURVEY AFFIDAVIT
Project Name / Address:
Permit/Process number:
Project address: Parcel tax ID:
General Contractor Company:
General Contractor (Qualifier for the Firm):
Florida License or Registration number:
Address:
Telephone: Fax: Email:
NOTICE TO GENERAL CONTRACTOR
The General Contractor shall bear the responsibility of submitting a Spot Survey + Elevation Certificate to Building
Code Services Division for Zoning and Floodplain review, in a timely manner. In accordance with FBC_BCA 110.3(1)(a)
and per the direction of the Building Official, no inspection activity is allowed after the slab inspection has been
approved and the Spot Survey + Elevation Certificate has been approved by the Zoning Official/Certified Floodplain
Manager.
The General Contractor must notify the AHJ within 48 hours of approving slab inspection in accordance with F.S.
553.791(10). Notification shall include the date and time of approval.
No vertical construction activity shall occur until the Survey and Elevation Certificate are approved. Upon completion
of the project, an Elevation Certificate and/or Flood Proofing Certificate & Final Survey is required to be submitted to
the Building Official in order to receive a TCO (Temporary Certificate of Occupancy), PCO (Partial Certificate of
Occupancy) or CO (Certificate of Occupancy).
I understand that I am subject to enforcement action by the AHJ if the above directives are not adhered to in the
time frames specified in this affidavit. I also understand that any permit issued by Building Code Services Division
pursuant to this affidavit holds the General Contractor responsible for maintaining compliance with this policy and all
other Local Jurisdiction Floodplain Ordinances.
X _
Signature of Qualifier for General Contractor
STATE OF
COUNTY OF _
Sworn to (or affirmed) and subscribed before me this day of
, 20 by:
(Type / Print Qualifier Name)
_
(NOTARY’S SIGNATURE as to Qualifier)
Notary Name
(Print, Type or Stamp Notary’s Name)
NOTARY SEAL
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 19 of 20
Personally, Known or Produced Identification
Type of Identification Produced
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | BUILDING PERMITTING
2307 West Broward Boulevard, Suite 300, Fort Lauderdale, Florida 33312 • 954-765-4400 • FAX 954-765-4410
Page 20 of 20
PRIVATE PROVIDER
SPOT SURVEY AFFIDAVIT
Project Name / Address:
Permit/Process number:
Project address: Parcel tax ID:
Private Provider Firm:
Private Provider (Qualifier for the Firm):
Florida License or Registration number:
Address:
Telephone: Fax: Email:
NOTICE TO PRIVATE PROVIDER
The Private Provider shall bear the responsibility of submitting a Spot Survey + Elevation Certificate to Building Code
Services Division for Zoning and Floodplain review in a timely manner. In accordance with FBC_BCA 110.3(1)(a) and
per the direction of the Building Official, no inspection activity is allowed after the slab inspection has been approved
and the Spot Survey + Elevation Certificate has been approved by the Zoning Official/Certified Floodplain Manager.
The Private Provider must notify the AHJ within 48 hours of approving slab inspection in accordance with F.S.
553.791(10). Notification shall include the date and time of approval.
No vertical construction activity shall occur until the Survey and Elevation Certificate are approved. Upon completion
of the project, an Elevation Certificate and/or Flood Proofing Certificate & Final Survey is required to be submitted to
the Building Official in order to receive a TCO (Temporary Certificate of Occupancy), PCO (Partial Certificate of
Occupancy) or CO (Certificate of Occupancy).
I understand that I am subject to enforcement action by the AHJ if the above directives are not adhered to in the
time frames specified in this affidavit. I also understand that any permit issued by Building Code Services Division
pursuant to this affidavit holds the private provider responsible for maintaining compliance with this policy and all
other Local Jurisdiction Floodplain Ordinances.
X _
Signature of Agent for Private Provider
STATE OF
COUNTY OF _
Sworn to (or affirmed) and subscribed before me this day of
, 20 by:
(Type / Print Agent Name)
_
(NOTARY’S SIGNATURE as to Agent)
Notary Name
(Print, Type or Stamp Notary’s Name)
Personally, Known or Produced Identification
Type of Identification Produced
NOTARY SEAL
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BUILDING CODE SERVICES DIVISION BUILDING PERMITTING (Broward County)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document