Department of Inspection and Standards
Jorge O. Elorza, Mayor
Joseph M. Atchue, Director/Building Official
Kevin Mahoney, Deputy Director
Mayor Joseph A. Doorley Municipal Building
444 Westminster Street | Providence, Rhode Island 02903 | 401-680-5201 | 401-680-5482 (fax)
www.providenceri.com
Permit-Terms of Agreement:
1. I am the owner or have obtained authorization from the owner of the property, to perform the
work described above.
2. During the construction of the permitted work, I will obtain all necessary inspections in a timely
manner. I understand that failure to obtain all inspections may result in violations, fines, fees,
penalties in accordance with the law.
3. I have provided a true and accurate projected cost of construction (materials and labor) for
which I have supporting documents and I will inform Inspection and Standards if there is any
change in scope and/or cost to the project.
4. The City of Providence has the right to inspect the property during the period in which the
permitted work is ongoing. The City of Providence further reserves the right to request
documentation to verify the cost of work provided.
5. I hereby affirm that the statements and representations on this form are true and accurate. I
understand that knowingly making a false statement to a governmental entity is a violation of
State law and could result in the revocation of any benefit granted pursuant to those statements
as well as criminal prosecution, significant civil penalties, and damages under common law and
the State False Claims Act.
I accept the above terms and responsibilities of this Permit
Signature:______________________________________________ Date:____________
Print Full Name:__________________________________________________________
Location of Work:_________________________________________________________
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