This affidavit certifies that the party listed, who is not a lessee, licensed architect, engineer, or contractor, has been granted
authorization to obtain a permit(s) on behalf of a property owner. It must be filled out completely by the property owner if another
party is submitting an application(s) on the owner’s behalf. This form must be notarized and must be submitted prior to issuance.
Copies of affidavits are unacceptable.
I, ________________________________, owner of the property listed below certify that I have granted,
________________________________________________, my duly authorized agent, permission to
obtain the permits necessary for the construction (or installation) of ________________________________
________________________________________________________________ at the following address:
(include suite # if applicable)
I understand that the permits obtained pursuant to this affidavit will be in my name and that I am acting as
contractor for this project. I accept full responsibility for the work performed.
_______________________________________________ _______________________
Signature of property owner Date
STATE OF ___________________________:
CITY OF _____________________________:
I, ______________________________, a Notary Public in and for the aforesaid State hereby certify that __
__________________________ appeared before me in the State and City aforesaid and executed this
affidavit on this ________ day of ____________________, _______.
My Commision Expires the ________ day of ____________________, _______.
Note to property owners:
If you made arrangements with a contractor to do this work, the City of Virginia Beach strongly suggests that the contractor be
the party to secure the necessary permit(s). When contractors obtain a permit in their name, they indicate their responsibility for
the work. When you sign this affidavit you are obtaining a permit(s) in your name for work that will be performed by a
contractor. This should be avoided. When a permit is issued solely in the name of the property owner, enforcement actions
against the contractor for code violations become more difficult. In addition, when the contractor applies for the permit, the City
will verify that the contractor is licensed as required by state and local laws. Unwillingness on the part of a contractor to obtain
the necessary permit(s) may be an indication that the contractor is not properly licensed. If you have any questions regarding this
matter, please call the Permits and Inspections Division at (757) 385-4211 prior to signing this form.
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