PRIVATE PROVIDER
Compliance Affidavit
City of Tampa Permit No.: _____________________________________________________________________________
Project Address: ____________________________________________________Project Folio No.:__________________
Private Provider Firm:_______________________________________________ License No.:_______________________
Office Phone: _____________________________________________Cell Phone: ________________________________
Email: ____________________________________________________________________________________________
Select all that apply:
Construction Plans Resubmittals (Response to deficiencies) Revisions (changes to original scope)
I HEREBY CERTIFY that to the best of my knowledge and belief, the documents submitted for the above referenced project
were reviewed according to, and are in compliance with, the Florida Building Code and all local amendments thereto,
either by myself or by the affiant identified below, who is duly authorized to perform plans review pursuant to Section
553.791, Florida Statutes, and holds the appropriate license or certificate:
________________________________________ _______________________________________
Printed or Typed Name of Private Provider Signature of Private Provider
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
