Fillable PERMIT APPLICATION BUILDING DIVISION DEPARTMENT FOR COMMUNITY SUSTAINABILITY (City of Lake Worth Beach)

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PERMIT APPLICATION BUILDING DIVISION DEPARTMENT FOR COMMUNITY SUSTAINABILITY (City of Lake Worth Beach)

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U.S.A. forms for City of Lake Worth Beach

BROWSE CITY OF LAKE WORTH BEACH (FL) FORMS

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Building Division | Department for Community Sustainability
City of Lake Worth Beach | 1900 2
nd
Avenue North | Lake Worth Beach,
FL 33461
WORK LOCATION
CONTRACTOR
BUILDING DIVISION
DEPARTMENT FOR COMMUNITY SUSTAINABILITY
CITY OF LAKE WORTH BEACH
1900 2
ND
AVENUE NORTH
LAKE WORTH BEACH, FL 33461
561.586.1647
PERMIT APPLICATION
MASTER PERMIT NUMBER
PERMIT NUMBER (FOR OFFICE USE ONLY)
ADDRESS _______________________________________________________
FLOOR/BAY/SUITE/APT # __________________________________________
SUBDIVISION _________________________ BLOCK ________ LOT _______
PARCEL ID#
38 – 43 – 44- ___________________________________
QUALIFIER NAME ____________________________________________________
COMPANY NAME _____________________________________________________
ADDRESS _____________________________________________________
CITY ________________________ STATE _________ ZIP _______________
STATE LIC. OR COMPETENCY # _________________________________________
PHONE# ___________________________ CELL#___
______________________
E-MAIL ____________________________________________________________
OWNER OF RECORD
NAME LAST FIRST MI
___________________________________________________________________________
ADDRESS __________________________________________________________________
CITY ____________________________ STATE ____________ ZIP _______________
PHONE _________________________________ CELL ___________________________
TENANT NAME______________________________________________________________
DESCRIBE PROJECT IN DETAIL
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
VALUE $__________________ SQUARE FOOTAGE_______________ CHANGE OF OCCUPANCY OR USE YES
NO
STATE LIC/CERT. OF COMPETENCY BUILDING PERMIT #
Building Contractor: ______________________________________________ DATE
Qualifier/Agent Signature ___________________________________________
PRIMARY PERMIT FEES
SHALL INCLUDE THE FEES FOR SUBPERMITS, PROVIDED THAT ALL APPLICABLE SUBCONTRACTOR
QUALIFIER SIGNATURES ARE ON THE APPLICATION AND PLANS INCLUDE THE DETAILS OF ALL SUBCONTRACTOR WORK. FAILURE TO
INCLUDE THE REQUIRED INFORMATION AT THE TIME OF APPLICATION SHALL REQUIRE THAT A SEPARATE PERMIT BE ISSUED WITH
APPROPRIATE FEES BEING CHARGED TO THE APPLICANT. CURRENT REGISTRATION REQUIRED AT TIME OF SUBMITTAL.
ELECTRICAL PERMIT #
Electrical Contractor: _____________________________________________ DATE
Mechanical Contractor: ____________________________________________ DATE
Qualifier/Agent Signature ___________________________________________
Plumbing Contractor: _____________________________________________ DATE
Qualifier/Agent Signature___________________________________________
STATE LIC/CERT. OF COMPETENCY
STATE LIC/CERT. OF COMPETENCY
STATE LIC/CERT. OF COMPETENCY
STATE LIC/CERT. OF COMPETENCY
MECHANICAL PERMIT #
PLUMBING PERMIT #
ROOFING PERMIT #
□ STRUCTURE □ DEMOLITION □ ELECTRICAL
□ ADDITION □ RELOCATION □ MECHANICAL
□ ALTERATION □ ROOFING □ PLUMBING
□ REPAIR □ FENCE □ POOL
□ FIRE SPRINKLER □ SIGN □ IRRIGATION
□ FIRE ALARM □ SIDEWALK □ BACKFLOW
□ DRIVEWAY □ GAS □ CHANGE OF CONTRACTOR
□ APPROACH □ FUEL □ GENERATOR
□ RESIDENTIAL □ COMMERCIAL □ DOOR
□ WINDOW □ SHUTTER □ OTHER
PERMIT TYPE
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Building Division | Department for Community Sustainability
City of Lake Worth Beach | 1900 2
nd
Avenue North | Lake Worth Beach,
FL 33461
NOTICE TO PROPERTY OWNERS
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE
EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION
713.13,
FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT 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.
BEFORE ANY WORK IS DONE BY YOU OR YOUR CONTRACTOR, IMMEDIATELY FILE FOR AND RECORD A NOTICE OF COMMENCEMENT WITH THE OFFICE OF THE CLERK OF THE
CIRCUIT COURT. THIS STEP IS REQUIRED BY THE FLORIDA CONSTRUCTION LIEN LAW.
IF YOU HAVE HIRED A CONTRACTOR TO DO THE WORK, MAKE SURE THAT THE CONTRACTOR OBTAINS THE PERMIT. THE CONTRACTOR’S SIGNATURE INDICATES HE OR SHE IS
RESPONSIBLE FOR THE WORK, AND IF THE WORK IS NOT PERFORMED ACCORDING TO CODE, THE CITY CAN REQUIRE CORRECTIVE ACTION BY THE PARTY WHO OBTAINED THE
PERMIT. FURTHERMORE, IF THE CONTRACTOR IS NOT LICENSED, YOU CAN BE IN VIOLATION OF STATE LAW BY ALLOWING AN UNLICENSED PERSON TO DO THIS WORK.
SINCE YOU OR YOUR CONTRACTOR HAVE APPLIED FOR A BUILDING PERMIT FOR WORK TO BE DONE ON PROPERTY YOU OWN, YOU SHOULD BE AWARE THAT:
ANY PERSON WHO FURNISHED LABOR (A CONTRACTOR, SUBCONTRACTOR OR LABORER) OR SUPPLIES MATERIALS FOR YOUR HOME REPAIR, IMPROVEMENT OR NEW
CONSTRUCTION MAY BE ABLE TO FILE A CLAIM (CALLED A LIEN) AGAINST YOU IF HE HAS NOT BEEN PAID BY YOUR CONTRACTOR OR YOU. YOU ARE LIABLE TO SUBCONTRACTORS
OR SUPPLIERS IF THEY ARE NOT PAID BY YOUR CONTRACTOR OR YOURSELF.
AT THE COMPLETION OF WORK, REQUIRE THE CONTRACTOR TO GIVE YOU A SWORN NOTARIZED STATEMENT INDICATING ALL BILLS FOR LABOR AND MATERIALS HAVE BEEN PAID OR
A LIST NAMING THOSE SUPPLYING LABOR AND MATERIALS THAT HAVE NOT BEEN PAID. ASK FOR THE AFFIDAVIT BEFORE MAKING THE LAST PAYMENT.
UNLICENSED CONTRACTORS: NO PERSON SHALL ENGAGE IN BUSINESS OR ACT IN THE CAPACITY OF A CONTRACTOR WITHOUT BEING DULY REGISTERED
OR CERTIFIED. ANY PERSON WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR OF THE FIRST DEGREE AND MAY BE PUNISHED BY A PRISON
TERM NOT EXCEEDING ONE (1) YEAR AND/OR A FINE NOT TO EXCEED $1,000 (SECTION 489.127 FLORIDA STATUTES).
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 ACQUIRED FOR ELECTRICAL WORK, PLUMBING,
SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, ROOFING 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 & ZONING.
FEE SIMPLE TITLEHOLDER (If other than owner)
Name ________________________________________________________________
____________
Address ________________________________________________________________
__________
City ______________________________________ State________________ Zip
______________
MORTGAGE LENDER
Name ________________________________________________________________
____________
Address ________________________________________________________________
__________
City ______________________________________ State _______________ Zip
______________
BONDING COMPANY
Name ________________________________________________________________
____________
Address ________________________________________________________________
__________
City ______________________________________ State________________ Zip
______________
ARCHITECT/ENGINEER/RESIDENTIAL PLANS CERTIFIER
I CERTIFY THAT THE PLANS ACCOMPANYING THIS DOCUMENT MEET ALL REQUIREMENTS PERTAINING TO
BUILDING CONSTRUCTION IN THE CITY OF LAKE WORTH.
Name ________________________________________________________________
____________
Signature ________________________________________________________________
________
Address ________________________________________________________________
__________
City ______________________________________ State _______________ Zip
______________
Phone ( ) ________________ Cell ( ) _________________ Fax ( )
_________________
Owner (Signature) ______________________________________________
Pr
int Name ____________________________________________________________
STATE OF ______________________
COUNTY OF ____________________
Sworn to (or affirmed) and subscribed to before me this _____________day of
_______________________ 20 _______ by Owner or Agent, who has produced the
following identification __________________________________________ or who
is personally known to me.
_____________________________________
Signature of Notary
_____________________________________
Print Name of Notary
STATE OF ______________________
COUNTY OF ____________________
Sworn to (or affirmed) and subscribed to before me this ___________ day of
__________________________ 20 _______ by Contractor, who has
produced the following identification
__________________________________________ or who is personally
known to me.
____________________________________
Signature of Notary
____________________________________
Print Name of Notary
Contractor/Agent (Signature) ________________________________
__________
Print Name ________________________________
_________________________
ALL SIGNATURES MUST BE ORIGINAL
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PERMIT APPLICATION BUILDING DIVISION DEPARTMENT FOR COMMUNITY SUSTAINABILITY (City of Lake Worth Beach)

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Completed 18 January 2021

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