Fillable UNIVERSAL COUNTY-WIDE BUILDING PERMIT APPLICATION FORM July 2013

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UNIVERSAL COUNTY-WIDE BUILDING PERMIT APPLICATION FORM July 2013

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  • 32 check-boxes
  • 114 other fields

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UNIVERSAL COUNTY-WIDE/MUNICIPAL
BUILDING PERMIT APPLICATION FORM
July 2013 Edition
Approved for use throughout Palm Beach County and Municipalities
FOR OFFICE USE ONLY
FBC Version:______________ Permit Type: _______________
Accepted By:____________ Application Date: _____________
Application #:________________________________________
1
KIND of PERMIT (CHECK ONE):
□ PRIMARY PERMIT
□ SUB-PERMIT - If Fee & Value of a Sub-Permit are
covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 &
8 only to apply. If not covered under a Primary Permit,
complete the entire application to apply.
2
PROPERTY OWNER:_______________________________________
TENANT:________________________________________________
ADDRESS: ____________________________________UNIT:______
CITY: __________________________STATE: ______ZIP:__________
PHONE: __________________________FAX:___________________
EMAIL:__________________________________________________
3
TRADE (CHECK ONE):
□ STRUCTURAL □ ROOFING □ ELECTRICAL
□ MECHANICAL □ PLUMBING □ FIRE □ GAS
□ OTHER: _______________________________
PRIMARY PERMIT #: _____________________
4
PROJECT NAME: _____________________________________________
PCN: __ __- __ __- __ __- __ __- __ __- __ __ __- __ __ __ __
LEGAL DESCRIPTION:__________________________________________
ADDRESS: ___________________________________________________
CITY: _______________________________________________________
5
FURTHER WORK DESCRIPTION: ____________________________________________________________________________
Type of Work: □ New □ Addition □ Alteration □ Repair □ Demo □ Temporary □ Other
VALUE: _____________ PERMIT FEE: ____________ NET S.F (for SFD’s): ____________
(SEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES)
6
□ OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
□ CONTRACTOR (CERT. HOLDER): _______________________________________________ License #: ________________________
DBA (COMPANY NAME): _______________________________________ Contact Person: ________________________________
ADDRESS: _____________________________________STE:______ CITY: ____________________STATE: ________ ZIP:________
PHONE: ____________________________ FAX: _______________________ EMAIL: ________________________________________
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 secured for ELECTRICAL
WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 and zoning.
7
________________________________________________________________________________
(Signature of Owner or Agent) (including contractor)
Print Name: _______________________________________
NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER /
BUILDERS REGARDLESS OF $ VALUE 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)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known ____ OR Produced Identification ______
Type of Identification Produced_______________________
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FEE SIMPLE TITLEHOLDER, BONDING COMPANY, ARCHITECT/ENGINEER AND MORTGAGE LENDER INFO IS REQUIRED WHEN THE
AGGREGATE VALUE (TOTAL COST OF ALL IMPROVEMENTS & NOT JUST WORK AUTHORIZED BY THE INDIVIDUAL PERMIT) IS $2,500 OR
MORE (EXCEPT HVAC REPAIR /REPLACEMENT < $7500). PLEASE ADDRESS ALL ITEMS.
9
10
Fee Simple Titleholder’s Name (If other than owner): ____________
Bonding Company: ________________________________
__________________________________________________________________
________________________________________________
Fee Simple Titleholder’s Address (If other than owner): _______
Bonding Company Address: _________________________
________________________________________________
________________________________________________
City: ___________________ State:_____ Zip: __________
City: _____________________ State:_____ Zip: __________
□ Same as Owner
□ Not Applicable
11
12
Architect/Engineer’s Name: ________________________
Mortgage Lender’s Name: ___________________________
________________________________________________
__________________________________________________
Architect/Engineer’s Name Address: _________________
Mortgage Lender’s Address: __________________________
________________________________________________
__________________________________________________
City: ______________________ State:_____ Zip: __________
City: ________________________ State:_____ Zip: __________
□ Not Applicable
□ Not Applicable
WARNING TO OWNER:
YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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.
NOTICE TO CONTRACTOR: FOR A DIRECT CONTRACT GREATER THAN $2,500 (EXCEPT FOR HVAC SYSTEM REPAIR OR
REPLACEMENT LESS THAN $7500), FLORIDA STATUTES REQUIRE THE APPLICANT TO FILE WITH THE ISSUING AUTHORITY,
PRIOR TO THE FIRST INSPECTION, EITHER A CERTIFIED COPY OF THE RECORDED (BY OWNER) NOTICE OF COMMENCEMENT
OR A NOTARIZED STATEMENT (BY OWNER) THAT THE NOTICE OF COMMENCEMENT HAS BEEN FILED FOR RECORDING,
ALONG WITH A COPY THEREOF. IN THE ABSENCE OF A CERTIFIED COPY OF THE RECORDED NOTICE OF COMMENCEMENT,
NO SUBSEQUENT INSPECTIONS CAN BE PERFORMED UNTIL THE APPLICANT FILES SUCH CERTIFIED COPY WITH THE ISSUING
AUTHORITY. THE CERTIFIED COPY OF THE NOTICE OF COMMENCEMENT MUST CONTAIN THE NAME AND ADDRESS OF THE
OWNER, THE NAME AND ADDRESS OF THE CONTRACTOR, AND THE LOCATION OR ADDRESS OF THE PROPERTY BEING
IMPROVED.
IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR
RECORDING YOUR NOTICE OF COMMENCEMENT.
OFFICE USE ONLY BELOW THIS LINE
13
CODE EDITION/NOTES: ______________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
14
USE (CHECK ONE):
□ 1 & 2 FAMILY □ TOWNHOUSE □ CONDOMINIUM
□ MULTI-FAMILY □ COMMERCIAL □ INDUSTRIAL
□ AGRICULTURAL - BLDG CODE EXEMPT □ OTHER: _____
_________________________________________________
□ USE CHANGE: ___________________________________
________________________________________________
15
APPROVED BY:________________________________________________________________ DATE:_____________________________
Permit Officer
AUTHORIZED FOR CERTIFICATE OF OCCUPANCY: _________________________________________________________DATE:___________________
Building Official or Designee
AUTHORIZED FOR CERTIFICATE OF COMPLETION: ________________________________________________________ DATE:___________________
Building Official or Designee
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UNIVERSAL COUNTY-WIDE BUILDING PERMIT APPLICATION FORM July 2013

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Completed 18 February 2020

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