OWNER
AGENT
U.C.C. F270 (rev. 8/2011)
SIGNED:
OWNER/AGENT
I hereby attest that to the best of my knowledge, the completed project meets the conditions of the construction
permit and all prior approvals, and all work has been completed substantially in accordance with the code and with
those portions of the plans and specifications controlled by the code, with any substantial deviations noted. Incom-
plete items listed on a Temporary Certificate of Occupancy will be completed by the date on the Certificate.
DESCRIPTION OF WORK/USE:
If you are requesting a Temporary Certificate of Occupancy, please explain why in the space below.
FINAL COST OF CONSTRUCTION:
(Include value of any new structure, all on-site improvements, built-in furnishings and fixtures and all integral
equipment exclusive of process or manufacturing equipment.)
$
USE GROUP
Previous
Current
ACTION
CERTIFICATE OF CONTINUED OCCUPANCY
LEAD HAZARD ABATEMENT CERTIFICATE OF CLEARANCE
TEMPORARY CERTIFICATE OF OCCUPANCY
IDENTIFICATION
Describe below any substantive deviation in dimension, lay out or appearance of the building or structure from the
released plans and specifications filed with the construction permit application. Please note, a set of amended
drawings may be required.
Permit #
Date Issued
Certificate Application Received:
Certificate Issued:
Address
- or -
Control #
APPLICATION FOR
CERTIFICATE
CERTIFICATE OF OCCUPANCY
*
Work Site Location
Block
Lot
Qualification Code
Contractor
Owner in Fee
Address
Tel.
Tel.
License No.
Federal Employee No.
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