Fillable Miscellaneous Application (Revize)

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Miscellaneous Application (Revize)

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The Miscellaneous Application (Revize) form is 2 pages long and contains:

  • 2 signatures
  • 3 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

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Miscellaneous Application
PERMIT #
DATE
CLERK
Payment method:
CONTRACTOR INFORMATION
Contractor Business Name:
License Holder’s Name:
Mailing Address:
City License #:
City:
State:
State License #:
Phone #:
Fax #:
Contact Person:
To Construct:
Email:
PROPERTY INFORMATION
Property Owner:
Strap #:
Site Address:
City:
State:
Block/Lot:
Phone #:
Fax:
Unit:
Existing use:
Proposed Use:
Setback Distances:
North
South
East
West
Zoned:
Foundation:
Corner Lot
:
Waterfront Property:
(Commercial Only)
Water Usage:
Lawn Irrigation System:
Construction Type:
Heads in right of way:
Clean-up Contractor Name:
If “YES” Check One or select n/a:
n/a
PIPING TO RUN PARALLEL TO ROAD PIPING TO RUN PERPENDICULAR TO ROAD
Valuation $
Application is hereby made to obtain a permit to do the work and installation 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 further certify that I have entered into a contract
with the owner/agent of the subject property to make the specified improvements to, or perform the contracting at,
the real property specified in this application. I have also made the owner/agent aware of the provisions of the
Homebuyers Protection Act. I certify that all the foregoing information is accurate, the city has been advised of all
easements on the property and all work will be done in compliance with all applicable laws regulating construction
and zoning. I acknowledge and accept responsibility for compliance with the current Florida Building Code,
regulations, and ordinances, as well as the payment of all legally constituted fees regarding this development
application, including but not limited to ALL REVIEW FEES, PERMIT FEES, AND IMPACT FEES. I understand that
a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES,
BOILERS, HEATERS, TANKS AND AIR CONDITIONERS, etc. NOTICE: In addition to the requirements of this
INITIALS
Revised
Page 1 of 2
Miscellaneous application.docx
10/30/2018
I I
permit, there may be additional restrictions to this property that may be found in the public records of this county or
that may be required from other governmental entities such as water management district, state agencies or federal
agencies.
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.
OWNER’S ELECTRONIC SUBMISSION STATEMENT: Under penalty of perjury, I declare that all the information
contained in this building permit application is true and correct.
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 COMENCEMENT 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.
I hereby acknowledge that I have read and understand the above affidavit on the day of
, 20 .
APPLICANT (PLEASE TYPE OR PRINT)
SIGNATURE OF APPLICANT
(SIGNATURE MUST BE NOTARIZED)
STATE
, COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of , 20 , by
who is personally known or produced
as identification.
Signature of Notary Public:
Printed name of NotaryPublic:
FOR OFFICE USE ONLY
Building Approval by:
Date:
Zoning Approval by:
Date:
Species Approved by:
Date:
Fire Approved by:
Date:
Surface Water Approved by:
Date:
Released by (Permit Tracker):
Date:
Issued by (Building Clerk):
Permit #
Issue Date:
Expiration Date:
Revised
Page 2 of 2
Miscellaneous application.docx
10/30/2018
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Miscellaneous Application (Revize)

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Completed 13 December 2021

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