UNIVERSAL COUNTY-WIDE/MUNICIPAL
BUILDING PERMIT APPLICATION FORM
July 2013 Edition
Approved for use throughout Palm Beach County and Municipalities
FOR OFFICE USE ONLY
FBC Version:______________ Permit Type: _______________
Accepted By:____________ Application Date: _____________
Application #:________________________________________
1
KIND of PERMIT (CHECK ONE):
□ PRIMARY PERMI
T
□ S
UB-PERMIT -
If Fee & Value of a Sub-Permit are
covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 &
8 only to apply. If not covered under a Primary Permit,
complete the entire application to apply.
2
PROPERTY OWNER:_______________________________________
TENANT:________________________________________________
ADDRESS: ____________________________________UNIT:______
CITY: __________________________STATE: ______ZIP:__________
PHONE: __________________________FAX:___________________
EMAIL:__________________________________________________
TRADE (CHECK ONE):
□ STRUCTURAL □ ROOFING □ ELECTRICAL
□ M
ECHANICAL □ PLUMBIN
G □ FIRE □
□ OTHER: _______________________________
PRIMARY PERMIT #: _____________________
PROJECT NAME: _____________________________________________
PCN: __ __- __ __- __ __- __ __- __ __- __ __ __- __ __ __ __
LEGAL DESCRIPTION:__________________________________________
ADDRESS: ___________________________________________________
CITY: _______________________________________________________
5
FURTHER WORK DESCRIPTION : ____________________________________________________________________________
Type of Work: □ New □ Addition □ Alteration □ Repair □ Demo □ Temporary □ Other
V
ALUE: _____________ PERMIT FEE: ____________ NET S.F (for SFD’s): ____________
(SEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES)
6
□ OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
□ CONTRACTOR (CERT. HOLDER): _______________________________________________ License #: ________________________
DB
A (COMPANY NAME): _______________________________________ Contact Person: ___________________
_____________
ADDR
ESS: _____________________________________STE:______ CITY: ____________________STATE: ________ ZIP:____
____
PHONE: ____________________________ FAX: _______________________ EMAIL: ________________________________________
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 this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL
WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS, etc.
OWNER’S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance
with all applicable laws regulating construction and zoning.
7
________________________________________________________________________________
(Signature of Owner or Agent) (including contractor)
Print Name
: _______________________________________
NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER /
BUILDERS REGARDLESS OF $ VALUE STATE OF FLORIDA
COUNTY OF _______________________________________
Sworn to (or affirmed) and subscribed before me this _______
day of __________________,
20 , by
8
________________________________________________________________________________
(Signature of Owner or Agent) (including contractor)
Print Name
: ________________________________________
NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER /
BUILDERS REGARDLESS OF $ VALUE STATE OF FLORIDA
COUNTY OF ________________________________________
Sworn to (or affirmed) and subscribed before me this _______
day of _____________________,
20_ , by
____________________________________________________
(Name of person making statement)
_________________________________________________
(Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known ____ OR Produced Identification ______
Type of Identification Produced_______________________
____________________________________________________
(Name of person making statement)
_________________________________________________
(
Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known ____ OR Produced Identification _______
Type of Identification Produced_______________________
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