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PERMIT DOCUMENTS Chw hCCL/9 {9 hb\[ 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 Czspo-!Dbnfspo KIND of PERMIT (CHECK ONE): PROPERTY OWNER:_______________________________________ PRIMARY PERMIT TENANT:________________________________________________ SUB-PERMIT -If Fee & Value of a Sub-Permit are 823!Njttjpo!Ijmm!Spbe ADDRESS: ____________________________________UNIT:______ covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 & 44546 GM Cpzoupo!Cfbdi CITY: __________________________STATE: ______ZIP:__________ 8 only to apply. If not covered under a Primary Permit, :65.6::.1924 complete the entire application to apply. PHONE: __________________________FAX:___________________ PRIVATE PROVIDER: PLAN REVIEW INSPECTIONS czspo593hnbjm/dpn EMAIL:__________________________________________________ 3 4 Dbnfspo-!Czspo TRADE (CHECK ONE): PROJECT NAME: _____________________________________________ STRUCTURAL ROOFING ELECTRICAL 761211121 194512 52 PCN: __ __-__ __-__ __-__ __-__ __-__ __ __-__ __ __ __ MECHANICAL PLUMBING FIRE GAS Dibqfm!Ijmm!F!96!GU!pg!MU!22'!X51!GU!pg!MU23!CML!21 LEGAL DESCRIPTION:__________________________________________ OTHER: _______________________________ 823!Njttjpo!Ijmm!SE PROJECT ADDRESS: _____________________________________________ PRIMARY PERMIT #: _____________________ Cpzoupo!Cfbdi CITY: _______________________________________________________ 5 Sfqmbdf!tnbmm!71!bnq!gvtf!qbofm FURTHER WORK DESCRIPTION: ____________________________________________________________________________ Type of Work: New Addition Alteration Repair Demo Temporary Other 2-959/11 (SEE FEE SCHEDULE) (AS APPLIES) (AS APPLIES) 6 OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE, FOR CONTACT INFORMATION SEE BOX 2) FD11113751 Spcfsu!H/!Nfttjoh CONTRACTOR (CERT. HOLDER): _______________________________________________ License #: ________________________ Fydfm!Fmfdusjdbm!Hspvq!JodSpcfsu!H/!Nfttjoh DBA (COMPANY NAME): _______________________________________ Contact Person: ________________________________ 4:67!Dpsbm!Sjehf!EsjwfDpsbm!Tqsjoht!GM/44176 ADDRESS: _____________________________________STE:______ CITY: ____________________STATE: ________ ZIP:________ :65.455.7874nbjmAfydfmfmfdusjdbmhspvq/dpn 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. hCCL/9 {9 hb\[ .9\[h IL{ \[Lb9 13 14 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 BQQSPWFE FMFDUSJD cbmvzpun!1202903133 BQQSPWFE FMFDUSJD cbmvzpun!1202903133 BQQSPWFE FMFDUSJD cbmvzpun!1202903133