Planning & 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
Parcel Identification Number
________ ________ ________ _________ __________ _______
Township Range Section Subdivision Block/Parcel Lot
I, _______________________________________________________________, the Special
Inspector, and Architect/Engineer licensed and/or registered with the State of Florida, Registration
Number ___________________, and certified by the Florida Building Commission, hereby certify
that I, or a duly authorized representative shall perform the structural inspections in accordance with
the approved Structural Inspection Plan prepared by the Engineer or Architect of record on the
threshold building located at the above referenced location. Further, I hereby agree to file, as
required by the Building Official, inspection reports under seal which accurately reflect the quality
and progress of the above described structural work for said threshold building to the Architect/
Engineer, Owner, and Building Official. Further, upon completion of the building and prior to the
issuance of a Certificate of Occupancy, I, as the Special Inspector shall file a signed and sealed
statement with enforcement agency, in substantially the following form: “To the best of my
knowledge and belief, the above described construction of all structural load bearing
components complies with the permitted documents, and the shoring and re-shoring
conforms with the shoring and re-shoring plans submitted to the enforcing agency.
_______________________________ ____________________
Signature of Special Inspector Date
Subscribed and sworn to before me this _____ day of _______________, 20 ______, personally
appeared _____________________________________ who is personally known to me or produced
_________________________________________ as identification, and who did/did not take an
Notary Public Signature Seal