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CPF (Pinellas County Government)

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Pinellas County Florida
Central Permit Form
(727) 464-3888 – 440 Court Street Clearwater, FL 33756
CB
HAB
WT/SP #
UP
File Reference #
Set #
RUP
In all cases, Combination Permits are issued that include the work of all trades described in the work description, construction plans and documents and/or are
required to complete the project. All portions identified as Applicant Portions must be completed to avoid processing delays.
Type of Permit Requested -
Zoning
Flood
Utilities Eng
Habitat
ROW
W/T-DRS Bldg
Applicant Portion
Date of Application:
/
/
Applicant:
Owner
Contractor
Contact #
e-mail
Agent
Owner
Contact #
Address
City
State
Zip
Fee Simple Titleholder (If Other Than Owner)
Contact #
Address
City
State
Zip
Contractor
License #
Company
Contact #
e-mail
Address
City
State
Zip
Project/Subproject Name
Job Address
PID#
/
/
/
/
/
Subdivision
Work Description:
Evaluation $____________________________
Bonding Company
Contact #
Address
City
State
Zip
Engineer
Reg #
Contact #
e-mail
Address
City
State
Zip
Architect
Reg #
Contact #
e-mail
Address
City
State
Zip
Mortgage Lender
Contact #
Address
City
State
Zip
WARNING 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.
Owner and Contractor Affidavit: Under penalty of perjury, I/We declare that all the information contained in this building permit application is true and correct. In addition, I/We certify that all
of the foregoing information is accurate and that all work will be done in compliance with all applicable law, codes and ordinances regulating construction and zoning.
Signature of Contractor/Agent*
Signature of Owner/Contractor**
X
X
Contractor/Agent
Name
Owner/Contractor Name
* When a Contractor assigns an agent the Contractor must provide a Notarized Authorization Letter.
**When Owner/Contractor exemption per f.s.489.103 (7) (a) is requested, the Owner must appear in person and no agent is permitted.
Central Permit Form – Revised 4/2017
Application/Permit # (Issued by County Staff) ____________________________ Job Name _____________________________________________________________
Applicant Portion Continued
New Building
Sq. Ft.
Addition
Sq.Ft.
Alteration
Sq. Ft.
Number of Units
Existing Building
Sq.Ft.
Retrofit/Repair Type
Sq. Ft.
Use of Building
1
st
Occupancy Type
Sq.Ft.
Egress Occupancy Load
Total Occupancy Load
2
nd
Occupancy Type
Sq.Ft.
Egress Occupancy Load
Total Occupancy Load
3
rd
Occupancy Type
Sq.Ft.
Egress Occupancy Load
Total Occupancy Load
Construction Type
Conditioned Space
Sq.Ft.
Project Valuation $
County Staff Portion
Zoning Review
Zoning
By
Units
Of
WT/Site Plan #
Setbacks -
Rear
BA#/Z#
Sign Calculations
Plan Review Only
Yes
No
Frontage
Left
Right
Allowed
Proposed
Front
Engineering Review
Drainage Review Approval Date
By
LFE=
NAVD88
Line of Sight Approval Date
By
Flood Review
Flood Zone
Required Elevation
By
Utility Review
Provider
PC Utility Fee Calculations
Size
Fee
Potable Water Source
Municipal Water
Potable Well
Water Tap Fee
Impact Fee
Waste Water Treatment
Municipal Sewer
Septic
Backflow
Sewer Connection
Grease Interceptor(s)
Yes
No
Number
Sewer Tap
Sewer Const Contribution Share
Review By
** Utility Fees Total
Fees
Building Services Fee Calculations
Fee Totals
Trade Section
By
Fees
Type of Fees
By
Fees
Building
Zoning Fees
Electrical
Habitat Management Fees
Low Voltage/Fire Alarm
Building Services *(see detail)
Plumbing
Miscellaneous Building Fees
Medical Gas
DBPR Surcharge
Fuel Gas
DCA Surcharge
Mechanical
Technology Fees
Sprinkler
Utility Fees **(see detail)
Hood
DRS Over-the-Counter Review - WT
Chemical
Site Plan Fees
Refrigeration
Palm Harbor Fire Fees
Fire Resistance / Life Safety
Multimodal District #
Plan Review
Paid
Yes
No
Contract Community Review
Right of Way Use Fees
Expedited – Additional Fee
Threshold
Violation #
x
* Building Fees Total
Total Due
Central Permit Form – Revised 4/2017
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CPF (Pinellas County Government)

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Completed 5 October 2020

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