DOCUMENTSUNIVERSAL COUNTY-WIDE/MUNICIPAL
BUILDING PERMIT APPLICATION FORM
July 2013 Edition
raved for use throughout Palm Beach County and Municipalities
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.
3
TRADE (CHECK ONE):
STRUCTURAL ❑ ROOFING ❑ ELECTRICAL
❑ MECHANICAL ❑ PLUMBING ❑ FIRE ❑ GAS
❑ OTHER:
PRIMARY PERMIT #: 0—c)
FOR OFFICE USE ONLY
FBC Version: Permit Type: _
Accepted By: Application Date:
Application
PROPERTY OWNI
TENANT:
-ADDRESS:>
9TY•
•
ONE•,
EMAIL: '
a
PROJECT NAME:
PCN: �as-la
LEGAL DESCRIPT
ADDRESS:
CITY: Q-,
' UNIT:
STATE: L_ ZIP•
FURTHER WORK DESCRIPTION:
Type of Work: ❑ New ❑ Addition ❑ Alteration WRepair ❑ Demo ❑ Temporary ❑ Other
v
VALUE:. '-` PERMIT FEE: NET S.F (for SFD's):
(SEE FEE SCHEDULE) (AS APPLIES)
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. - .
Z
Print Name: M I If 14 " 7
NOTARY REWIRED IF '$ 211500 O M
BUILDERS EG LESS 6 $ VALUE
COUNTY O
Sworn t or rmed tl su scrib
day o
UL-
A
__ Print Name:
)RE, OR FOR ALL OWNER / NOTARY REI
5T E OF FLORIDA BUILDERS RI
COUNTY OF
A b ore me this Sworn to
by day of
fE
(Signature of Notary Public - State of Florida)-' ( ,,,/ 1Z"
(Print, Type, or Stamp Commissioned Name of Notary Public) r
Personally Known OR Produced -Identification
Type of Identification Produced
IF $ 2,51110 OR MORE, OR FOR XLL OWNER /
Hbed b or me this
2 , by
(Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produ�ldent' cation
Type of Identification Produced
DEBRA DENISE MAZAKAS age 1 of 2
Notary Public - StateoFFlo"da ;'SSR P� ,• DEBRA DENISE MAZAKAS
Commission# GG 106440 �' ` Notary Public
-
StateafFlarida
My Comm. Expires May 18, 2021 :. P- Commission 4 GG 106440
My Comm. Expires May 18, 2021
10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the
United States Small Business Administration, the Florida Department of Financial Services, and the Florida Department of
Revenue. I also understand that I may contact the Construction Industry Licensing Board by calling 561-233-5525 or visiting their
website, http://www.12bcjzov.com/pzb/Contractors, for more information about licensed contractors.
11. I am aware of, and consent to, an owner -builder permit applied for in my name and understand that I am the party legally and
financially responsible for the proposed construction activity at the property address stated below.
12. I agree to notify the City of Boynton Beach Building Division immediately of any additions, deletions, or changes to any of the
information that I have provided on this disclosure.
Licensed contractors are regulated by laws designed to protect the public. If you contract with a
person who does not have a license, the Construction Industry Licensing Board and Department of
Business and Professional Regulation may be unable to assist you with any financial loss that you
sustain as a result of a complaint. Your only remedy against an unlicensed contractor may be in civil
court. It is also important for you to understand that, if an unlicensed contractor or employee of an
individual or firm is injured while working on your property, you may be held liable for damages. If you
obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for
verifying whether the contractor is properly licensed and the status of the contractor's workers'
compensation coverage.
To apply for an owner -builder permit, this form must be completed and submitted with the building
permit application package.
Property
Property
STATE G, .
COUNTY OF PALM BEACH
The
by_
before me this 14 day of (month), (year),
(printed name of signer).
Notary's signatur (Ju7
Notary's name, printed, typed or stamped
Personally known OR produced identification
Type of identification produced
Y pub -.
DEBRA DENISE MAZAKAS
Notary Public - State of Florida
Commission a GG 106440
t P:
MyComm, ExpiresMay tB,ZOZt