Fillable City of Pompano Beach Engineering Permit Application (City of Pompano Beach)

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City of Pompano Beach Engineering Permit Application (City of Pompano Beach)

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BROWSE CITY OF POMPANO BEACH (FL) FORMS

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City of Pompano Beach Engineering Permit Application
g/bldg/app/bldg.prmt.app Effective Date: 1-1-91 - per F.S. 713.135(6) Revised 10/ 7 /04 Page 1 of 2
Note to Applicant:
This form (Page 1 & 2) MUST have all applicable information to avoid delays.
Date of Application _____/_____/_____ Tax Folio # _________-____-_________ P.R.A. # ______-___________
Owner’s Name: _______________________________________________Phone #(______)_______-_________
Owner’s Address: _________________________________City _____________________State ___Zip________
Fee Simple Titleholder’s Name (if other than Owner):________________________________________________
Fee Simple Titleholder’s Address: __________________________City_______________ State ___Zip________
Contractor: __________________________________________________ Phone #(______)_______-_________
Certificate of Competency #: ___________________State Registration # (if applicable): ____________________
Contractor’s Address: _________________________________City__________________ State___Zip ________
Job Name & Description of Work ________________________________________________________________
Job Address ________________________________________________________________________________
Subdivision ___________________________________________________________Block_______ Lot _______
Bonding Company ___________________________________________________________________________
Bonding Company Address______________________________City_________________State___Zip ________
Engineer_________________________________Registration #____________Phone (_____) _____ - ________
Engineer Address______________________________________City_________________State ___Zip _______
Architect _________________________________Registration #___________ Phone (_____) _____ - ________
Architect Address_____________________________________City_________________State ___ Zip ________
Mortgage Lender’s Name______________________________________________________________________
Mortgage Lender’s 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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT
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 and that all work will be performed to meet the standards of all laws
regulating construction in the City of Pompano Beach. I understand that a separate permit must be secured for
ELECTRICAL
WORK, PLUMBING, SIGN, WELLS, POOLS, FURNACES, BOILERS, HEATERS TANKS and AIR CONDITIONERS etc.
Owner Affidavit: I certify that all the forgoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
Signature of Legal Owner/Agent: (Including Contractor with notarized statement) Signature of Legal Contractor:
X____________________________________________________
STATE OF FLORIDA - COUNTY OF BROWARD
Sworn to (or affirmed) and subscribed before me
this_______ day of ___________________________, 20______ by
______________________________________________________
(Type / Print Owner’s Name)
______________________________________________________
NOTARY’S SIGNATURE
as to Owner or Agent’s Signature
Name & Title (printed) ____________________________________
(Type / Print Notary’s Name)
Personally Known _____ or Produced Identification ______
Type of Identification Produced ____________________________
X______________________________________________________
STATE OF FLORIDA - COUNTY OF BROWARD
Sworn to (or affirmed) and subscribed before me
this_______ day of __________________________, 20_______ by
_______________________________________________________
(Type / Print Contractor’s Name)
______________________________________________________
NOTARY’S SIGNATURE
as to Contractor’s Signature
Name & Title (printed) ____________________________________
(Type / Print Notary’s Name)
Personally Known _____ or Produced Identification ______
Type of Identification Produced ____________________________
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City of Pompano Beach Engineering Permit Application
g/bldg/app/bldg.prmt.app Effective Date: 1-1-91 - per F.S. 713.135(6) Revised 10/ 7 /04 Page 2 of 2
ENGINEERING PERMIT INFORMATION
(DATA TO BE FURNISHED BY APPLICANT) P.R.A. # ______-___________
APPLICATION IS HERREBY MADE for permission to construct and maintain, within the Public Right-of-Way, Easement,
or Public Property, the below described project in accordance with the plans and specifications herewith submitted and
subject to all Codes, Ordinances and Regulations of the City of Pompano Beach, Florida, and all provisions of Federal,
State, and County laws.
IT IS AGREED by both the Owner and Contractor that the approval of plans and specifications does not relieve them of
the responsibility to comply with provisions of the City Code of Ordinances and that any facility constructed under this
permit is subject to the following:
1. Removal or relocation by the Owner as directed by the City Engineering Division at no cost to the City when the
facility conflicts with the location of existing or future City-Owned improvements.
2. Removal without repair or replacement by the City upon written notice by the City.
3. Construction inspections will be conducted by the City Engineering Division and if the improvements are found to
be contrary to the approved plans and specifications, the facilities will immediately be removed and reconstructed
to conform with the approved plans and specifications.
4. That after the plans and specifications have been approved by the City Engineering Division, they shall not be
changed without written approval of the Engineering Division.
THE OWNER AND CONTRACTOR FURTHER AGREE to indemnify, defend, and save harmless and exonerate the City
and its employees from all liabilities, claims, and demands for liability rising out of the work under this permit.
WORK DESCRIPTION
CONSTRUCTION CATEGORIES
Water Lines or Mains ____________________________
Sanitary Sewer _________________________________
Jack and Bore __________________________________
Boat Lift ______________________________________
Piles ________________________________________
Curbing ______________________________________
Irrigation Lines _________________________________
Paver Block Driveway____________________________
Storm Drainage __________________________________
Force Main ______________________________________
Utility Cut in R.O.W. _______________________________
Boat Dock _______________________________________
Dredging _______________________________________
Sidewalk _______________________________________
Landscape ______________________________________
Street Lighting ___________________________________
ONSITE PAVING (INCLUDING: Fill, Subgrade Preparation, Limerock Base, Asphalt, Signs, Wheel Stops, Curbing
and Striping.)________________________________________________________________________
PAVING WITHIN PUBLIC R.O.W. (INCLUDING: Fill, Subgrade Preparation, Limerock Base, Asphalt, Road
Markings, Signs, and Guardrails.) ______________________________________________________________
Miscellaneous: _____________________________________________________________________________
DESCRIPTION OF WORK
(To Be Typed On Permit)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
ESTIMATED PERMIT VALUE $ ______________________ PERMIT FEE $ _________________________
NOTE: A copy of a valid contract between the registered property owner must be submitted with this application so
that permits fees may be calculated.
Approved By: ______________________________________ Date: ____/____/____ _________ ___/ ___/ ___
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City of Pompano Beach Engineering Permit Application (City of Pompano Beach)

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Completed 4 August 2020

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