FOR OFFICE USE ONLY

UNIVERSAL COUNTY-WIDE/MUNICIPAL
BUILDING PERMIT APPLICATION FORM FBC Version:______________ Permit Type: _______________
January 2024 Edition Accepted By:____________ Application Date: _____________
Approved for use throughout Palm Beach County and Municipalities Application #:________________________________________
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KIND of PERMIT (CHECK ONE): PROPERTY OWNER:_______________________________________
□ PRIMARY PERMIT TENANT:________________________________________________
□ SUB-PERMIT - If Fee & Value of a Sub-Permit are ADDRESS: ____________________________________UNIT:______
covered under a Primary Permit, complete boxes 1, 3, 4, 5, 6 &
8 only to apply. If not covered under a Primary Permit, CITY: __________________________STATE: ______ZIP:__________
complete the entire application to apply. PHONE:
PRIVATE PROVIDER: □ PLAN REVIEW □ INSPECTIONS Email:__________________________FAX:___________________
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TRADE (CHECK ONE): PROJECT NAME: _____________________________________________

□ STRUCTURAL □ ROOFING □ ELECTRICAL PCN: __ __- __ __- __ __- __ __- __ __- __ __ __- __ __ __ __
□ MECHANICAL □ PLUMBING □ FIRE □ GAS
LEGAL DESCRIPTION:__________________________________________
□ OTHER: _______________________________
PROJECT ADDRESS: _____________________________________________
PRIMARY PERMIT #: _____________________
CITY: _______________________________________________________
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FURTHER WORK DESCRIPTION: ______________________________________________________________________________________

Type of Work: □ New □ Addition □ Alteration □ Repair □ Demo □ Temporary □ Other
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)
□ 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.
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________________________________________________________________________________ ________________________________________________________________________________
(Signature of Owner or Agent) (including contractor) (Signature of Contractor)

Print Name: _______________________________________ Print Name: ________________________________________

NOTARY REQUIRED IF $ 5,000 OR MORE, OR FOR ALL OWNER / NOTARY REQUIRED IF $ 5,000 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 ______________________________

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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 $5,000 OR
MORE (EXCEPT HVAC REPAIR /REPLACEMENT < $15,000). 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: ___________________________

________________________________________________ __________________________________________________
Architect/Engineer’s Name Address: _________________ Mortgage Lender’s Address: __________________________
________________________________________________ __________________________________________________
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 $5,000 (EXCEPT FOR HVAC SYSTEM REPAIR
OR REPLACEMENT LESS THAN $15,000), 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.
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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