PERMIT DOCUMENTS
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UNIVERSAL COUNTY-WIDE/MUNICIPAL
FBC Version:______________ Permit Type: _______________
BUILDING PERMIT APPLICATION FORM
Accepted By:____________ Application Date: _____________
January 2020 Edition
Application #:________________________________________
Approved for use throughout Palm Beach County and Municipalities
1 2
2531!IPMEJOHT
KIND of PERMIT (CHECK ONE): PROPERTY OWNER:_______________________________________
PRIMARY PERMIT TENANT:________________________________________________
2531!TX!41ui!Bwf
SUB-PERMIT -If Fee & Value of a Sub-Permit are
ADDRESS: ____________________________________UNIT:______
covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 &
44537
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CITY: __________________________STATE: ______ZIP:__________
8 only to apply. If not covered under a Primary Permit,
complete the entire application to apply.
PHONE: __________________________FAX:___________________
PRIVATE PROVIDER: PLAN REVIEW INSPECTIONS
EMAIL:__________________________________________________
3 4
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TRADE (CHECK ONE):
PROJECT NAME: _____________________________________________
STRUCTURAL ROOFING ELECTRICAL
761911111
1945115
5
PCN: __ __-__ __-__ __-__ __-__ __-__ __ __-__ __ __ __
MECHANICAL PLUMBING FIRE GAS
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LEGAL DESCRIPTION:__________________________________________
OTHER: _______________________________
2531!TX!41UI!BWF
PROJECT ADDRESS: _____________________________________________
PRIMARY PERMIT #: _____________________
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CITY: _______________________________________________________
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FURTHER WORK DESCRIPTION: ____________________________________________________________________________
Type of Work: New Addition Alteration Repair Demo Temporary Other
(SEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES)
6
OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
GFE29.111124
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CONTRACTOR (CERT. HOLDER): _______________________________________________ License #: ________________________
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DBA (COMPANY NAME): _______________________________________ Contact Person: ________________________________
3128!Dpsqpsbuf!esjwfCpzoupo!Cfbdi44537
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ADDRESS: _____________________________________STE:______ CITY: ____________________STATE: ________ ZIP:________
911.441.2269qfsnjutAmjgftbgfuz/ofu
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.
information is accurate and that all work will be done in compliance
with all applicable laws regulating construction and zoning.
7 8
________________________________________________________________________________ ________________________________________________________________________________
(Signature of Owner or Agent) (including contractor) (Signature of Contractor)
Print Name: _______________________________________ Print Name: ________________________________________
NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER / NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER /
BUILDERS REGARDLESS OF $ VALUE STATE OF FLORIDA BUILDERS REGARDLESS OF $ VALUE STATE OF FLORIDA
COUNTY OF _______________________________________ COUNTY OF ________________________________________
Sworn to (or affirmed) and subscribed before me this _______ Sworn to (or affirmed) and subscribed before me this _______
day of __________________, 20 , by day of _____________________, 20_ , by
____________________________________________________ ____________________________________________________
(Name of person making statement) (Name of person making statement)
_________________________________________________ _________________________________________________
(Signature of Notary Public -State of Florida) (Signature of Notary Public -State of Florida)
_________________________________________________ _________________________________________________
(Print, Type, or Stamp Commissioned Name of Notary Public) (Print, Type, or Stamp Commissioned Name of Notary Public)
Physical Presence _____ OR Online Notarization _____ Physical Presence _____ OR Online Notarization _____
Personally Known _____ OR Produced Identification _____ Personally Known _____ OR Produced Identification _____
Type of Identification Produced ______________________________ Type of Identification Produced ______________________________
Page 1 of 2
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
(If other than owner): ____________ Bonding Company: ________________________________
__________________________________________________________________ ________________________________________________
(If other than owner): _______ Bonding Company Address: _________________________
________________________________________________ ________________________________________________
City: ___________________ State:_____ Zip: __________ City: _____________________ State:_____ Zip: __________
Same as Owner Not Applicable
11 12
: ________________________ : ___________________________
________________________________________________ __________________________________________________
_________________ __________________________
________________________________________________ __________________________________________________
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.
FOR APPLICATIONS SUBMITTED UNDER THE PRIVATE PROVIDER PROVISIONS OF F.S. SECTION 553.791, THIS
APPLICATION IS NOT CONSIDERED COMPLETE OR SUFFICIENT FOR PURPOSES OF SUBMISSION TO THE BUILDING
DEPARTMENT UNTIL THE APPLICANT SECURES ALL NECESSARY APPROVALS FROM OTHER DEPARTMENTS OR
AGENCIES INCLUDING, BUT NOT LIMITED TO, PLANNING, ZONING, ENGINEERING, FIRE RESCUE,
ENVIRONMENTAL, AND THE FLORIDA DEPARTMENT OF HEALTH.
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CODE EDITION/NOTES: ______________________________ USE (CHECK ONE):
1 & 2 FAMILY TOWNHOUSE CONDOMINIUM
__________________________________________________
MULTI-FAMILY COMMERCIAL INDUSTRIAL
__________________________________________________
AGRICULTURAL -BLDG CODE EXEMPT OTHER: _____
__________________________________________________
_________________________________________________
__________________________________________________
USE CHANGE: ___________________________________
__________________________________________________
________________________________________________
Page 2 of 2
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