(Revised02/24/2014)
Bonding Company’s Name (if applicable) ___________________________________________________________________________
Bonding Company’s Address _____________________________________________________________________________________
City ___________________________ State _____________________________________ Zip ________________________________
Mortgage Lender’s Name (if applicable) ____________________________________________________________________________
Mortgage Lender’s Address ______________________________________________________________________________________
City ___________________________ State ______________________________ Zip___________________________
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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.
“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.”
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
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APPROVED BY _____________________________ Plans Examiner __________________________________ Zoning
_____________________________ Structural Review Clerk
Signature____________________________________________
OWNER or AGENT
The foregoing instrument was acknowledged before me this
_________ day of _____________________, 20 ________, by
___________________________, who is personally known to
me or who has produced ___________________________ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Signature____________________________________________
CONTRACTOR
The foregoing instrument was acknowledged before me this
_________ day of _____________________, 20 ________, by
___________________________, who is personally known to
me or who has produced ___________________________ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
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