Revised 01/06/21
Planning and Development Department
Building Code
2725 Judge Fran Jamieson Way
Building A, Room 114
Viera, Florida 32940
(321) 633-2187 Phone
Building Permit Number
Site Address
_____________________________ _______________________ ________ ____________
Street City State Zip Code
________ ________ ________ ________ ________ ________
Township Range Section Subdivision Block/Parcel Lot
I, ____________________________________________, the Owner of the threshold building
located at the above referenced location hereby agree to contract for the service of
___________________________________________________________, the Special
Inspector. In accordance with Florida Statute 553.79 and the Florida Building Code, I agree to
pay all costs of employing the Special Inspector. I hereby acknowledge that the Special
Inspector shall be responsible to the Brevard County Building Code Office. I understand that
no substitute may be made for this Special Inspector without written approval from the Building
Official. I further understand that if the Special Inspector is not on the job site as specified in
the Structural Inspection Plan, the Building Permit may be revoked by the Building Official.
Finally, upon completion of the building prior to issuance of a Certificate of Occupancy, I agree
to file a certificate prepared by the Architect or Engineer stating the construction of the project
complies with all applicable building codes AND the intent and design specified in the
permitted documents.
__________________________________________ __________________
Signature of Owner Date
Subscribed and sworn to before me, by ____ physical presence or ____ online notarization,
this ___________ day of, ______________________, 20______, personally appeared
________________________________, who is personally known to me or produced
________________________________ as identification, and who did/did not take an oath.
Notary Public Signature Seal