Form Aa 279 – Fill Out and Use This PDF

CITY OF FORT LAUDERDALEPERMIT APPLICATION

CITY OF

700 NW 19th Avenue, Fort Lauderdale FL 33311

F O RT L AU D E R D A L E

7 0 0 N . W. 1 9 T H AV E N U E , F O RT L A U D E R D A L E , F L O R I D A 3 3 3 1 1

Permit Type: ________________________ Master Permit # ___________________________ Sub Permit #___________________________

COMPLETE FORM IN BLACK INK - ONLY SIGNATURES MAY BE IN STANDARD BLUE INK

Owner’s Name _________________________________________________________ Phone # __________________________

Owner’s Street Address ____________________________________________________________________________________

City ________________________________ State ______ Zip Code _________ Owner’s Email _________________________

Fee Simple Titleholder’s Name (if other than owner) __________________________________________________________

Fee Simple Titleholder’s Address ____________________________ City ____________________ State ______ Zip________

Contractor’s Company Name _____________________________________________ Phone # _______________________

Contractor’s Business Address _______________________________ City ____________________ State _____ Zip _______

Contractor’s E-mail Address __________________________________________ Alternate Phone # ___________________

Qualifier’s Name _______________________________________________ State Certificate # _________________________

Broward County Certificate of Competency # ______________________ State Registration # ____________________

Job Address __________________________________________________ City ________________________________________

Legal Description: Subdivision ____________________________________ Lot _______ Block _______ Building # _______

Type of Property: ฀ Single family ฀ Duplex/Two-family ฀ Multi-Family ฀ Condominium ฀ Commercial

Description of Work to be Done _____________________________________________________________________________

For Office Use Only: Occupancy Type ________ Construction Type _______Lowest Floor Elevation ________ Flood Zone _______

Architect/Engineer _______________________________________ Reg. # _______________________ Phone #______________________

Architect/Engineer Address__________________________________ City _____________________________ State _____ Zip __________

Bonding Company _______________________________________ Address _____________________________________________________

Mortgage Lender ________________________________________ Address _____________________________________________________

Application is hereby made to obtain a permit to do the work and installation as indicated. I certify that no installation or work 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 the City of Fort Lauderdale, OR I acknowledge that this is an application for an After the Fact permit. I understand that a separate permit must be secured for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, DRIVEWAYS, ROOFS, 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. Furthermore, I authorize the above-named contractor to do the work stated.

WARNING TO OWNER: Your failure to record a notice of commencement may result in your paying twice for improvements to your property. If you intend to obtain financing, consult your lender or an attorney before recording your notice of commencement. The notice of commencement must be recorded at the Broward County Clerk of the Courts, Room 114, 115 S Andrews Ave, Fort Lauderdale FL 33301.