Palm Bay Building Permit Form – Fill Out and Use This PDF

ACCEPTED BY: ______________

DATE: ______________

APPROVED BY: ______________

DATE: ______________

BUILDING DIVISION

120 Malabar Road, S.E., Palm Bay, FL 32907

Phone: (321) 953-8924 ● Fax: (321) 953-8925

Construction Permit Application

“This application shall be completed in its entirety and shall not be altered in any way.”

Please visit our web site for forms at www.palmbayflorida.org

2010 EDITION OF THE FLORIDA BUILDING CODES AND THE 2008 EDITION OF THE NATIONAL ELECTRICAL CODE

Application Date:

Description of Work:

Application Number:

VALUE:

$

ZONING:

Job Name:

CHECK ONE:

RESIDENTIAL

COMMERCIAL

Job Address:

CITY :

COUNTY :

CONSTRUCTION TYPE:

CBS

FRAME

OTHER

LOT:

TWP:

COND. SQ. FT.:

FLD ZONE:

BLK/PAR :

RNG:

NON-COND. SQ. FT.:

ROOF PITCH:

SEC:

SUB# :

TOTAL SQ. FT.:

# SQUARES:

PROPERTY OWNER INFORMATION

CONTRACTOR INFORMATION

BUSINESS

NAME:

NAME:

ADDRESS:

ADDRESS:

CITY:

CITY:

STATE:

ZIP:

STATE:

ZIP:

PHONE:

PHONE:

(

)

-

FAX:

( )

-

FAX:

E-MAIL:

E-MAIL:

MORTGAGE LENDER’S NAME:

QUALIFIER:

CONTRACTOR’S CERTIFICATION OF

ADDRESS:

COMPETENCY NO.:

BONDING COMPANY:

CONTRACTOR’S STATE CERTIFICATION

ADDRESS:

OR REGISTRATION NO. :

CITY:

STATE:

ELECTRICAL

SUB CONTRACTOR INFORMATION

FEE SIMPLE TITLE HOLDER’S NAME:

CONTRACTOR:

(IF OTHER THAN OWNER)

ADDRESS:

FEE SIMPLE TITLE HOLDER’S ADDRESS:

PHONE#:

CERT. #:

(IF OTHER THAN OWNER)

PLUMBING

CONTRACTOR:

CITY:

STATE:

ZIP:

ADDRESS:

PHONE#:

CERT. #:

ARCHITECT/

HVAC

CONTRACTOR:

ENGINEER’S NAME:

ADDRESS:

ADDRESS:

PHONE#:

CERT. #:

CITY:

STATE:

ZIP:

1

BUILDING_PERMIT_APPLICATION

03/12 Revision G

APPLICANT’S AFFIDAVITS

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, FENCES, FURNACES, BOILERS, HEATERS, TANKS, AND AIR CONDITIONERS, etc.

“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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT

WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.”

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.

Signature of Owner or Agent

(including Contractor):

Date:

STATE OF FLORIDA

COUNTY OF ____________________

Sworn to (or affirmed) and subscribed before me this

day of

20

,by

Personally Known

OR Produced Identification

Type of Identification:

Signature of Notary Public, State of Florida

Print or Stamp Name

2

BUILDING_PERMIT_APPLICATION

03/12 Revision G