PRIVATE PROVIDER CERTIFICATE OF COMPLIANCE
REQUEST FOR CERTIFICATE OF OCCUPANCY OR CERTIFICATE OF COMPLETION
City of Tampa Permit No.: ______________________________________________________________
Project Address: ________________________________________________________________
Private Provider Firm: ________________________ Qualifier Name: ______________________
Phone: ____________________________ Email: __________________________________
I HEREBY ATTEST that to the best of my knowledge, belief and professional judgment, the building components
and site improvements captioned above have been inspected under my authority, as indicated in the inspections
report, and have been completed in substantial compliance with the approved documents, plans, revisions,
and applicable codes; and, I FURTHER ATTEST that to the best of my knowledge, belief and professional
judgment, there are no known issues relating to life safety which would preclude the issuance of the following:
Certificate of Occupancy Temporary Certificate of Occupancy (TCO)
Certificate of Completion Partial Certificate of Occupancy (PCO)
Printed Name of Private Provider Qualifier License No. Signature of Private Provider Qualifier
NOTARY
STATE OF FLORIDA
COUNTY OF
SWORN TO (OR AFFIRMED) AND SUBSCRIBED before me this day of ______________,
20 , by (name of person making statement).
Signature of Notary Public – State of Florida
(NOTARY SEAL)
Printed or Typed Name of Notary Public
