PERMIT DOCUMENTS
FOR OFFICE USE ONLY
UNIVERSAL COUNTY-WIDE/MUNICIPAL
FBC Version:______________ Permit Type: _______________
BUILDING PERMIT APPLICATION FORM
Accepted By:____________ Application Date: _____________
July 2013 Edition
Application #:________________________________________
Approved for use throughout Palm Beach County and Municipalities
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KIND of PERMIT (CHECK ONE): PROPERTY OWNER:_______________________________________
PRIMARY PERMIT TENANT:________________________________________________
SUB-PERMIT - If Fee & Value of a Sub-Permit are
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ADDRESS: ____________________________________UNIT:______
covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 &
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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:___________________
EMAIL:__________________________________________________
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TRADE(CHECK ONE):
PROJECT NAME: _____________________________________________
STRUCTURAL ROOFING ELECTRICAL
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PCN: __ __- __ __- __ __- __ __- __ __- __ __ __- __ __ __ __
MECHANICAL PLUMBING FIRE GAS
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LEGAL DESCRIPTION:__________________________________________
OTHER: _______________________________
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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
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VALUE: _____________ PERMIT FEE: ____________ NET S.F (for SFD’s): ____________
(SEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES)
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OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2)
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CONTRACTOR (CERT. HOLDER): _______________________________________________ License #: ________________________
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DBA (COMPANY NAME): _______________________________________ Contact Person: ________________________________
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ADDRESS: _____________________________________STE:______ CITY: ____________________STATE: ________ ZIP:________
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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.
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________________________________________________________________________________ ________________________________________________________________________________
(Signature of Owner or Agent) (including contractor) (Signature of Owner or Agent) (including contractor)
Print NamePrint 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)
Personally Known ____ OR Produced Identification ______
Personally Known ____ OR Produced Identification _______
Type of Identification Produced_______________________
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.
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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
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Architect/Engineer’s Name: ________________________ Mortgage Lender’s Name: ___________________________
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________________________________________________ __________________________________________________
Architect/Engineer’s Name Address: _________________ Mortgage Lender’s Address: __________________________
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________________________________________________ __________________________________________________
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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
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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: ___________________________________
__________________________________________________
________________________________________________
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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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