PRIVATE PROVIDER PLAN COMPLIANCE AFFIDAVIT
Permit #: _______________________ Address: _________________________________________
Private Provider Firm: ______________________________________________________________
Private Provider: ___________________________________________________________________
Address: _________________________________________________________________________
Phone: ___________________________________________________________________________
E-mail: ___________________________________________________________________________
Notice - A private provider may only perform building code plan review services that are within the disciplines
covered by that person’s licensure or certification.
I hereby certify that to the best of my knowledge and belief the plans submitted were reviewed for and are in
compliance with the Florida Building Code and all local amendments to the Florida Building Code by the
following affiant, who is duly authorized to perform plans review pursuant to Section 553.791, Florida Statute
and hold the appropriate license or certificate.
Plan sheets: _______________________________________________________________________
Florida Architect’s or Engineer’s Certification #: ______________________________________________
Signature of Private Provider: ___________________________________________________________
STATE OF FLORIDA, COUNTY OF ______________________________________________________
Sworn to and subscribed before me this _______ day of ____________20 ____, by: _________________
[ ] Personally known [ ] Procured Identification – Type of Identification____________________________ and
who being fully sworn and cautioned, states that the foregoing is true and correct to the best of his/her
knowledge or belief.
__________________________
_______________________________
Signature of Notary Public
