Engineering Permit Application Form
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2City of Pompano Beach
Engineering Permit Application
Note to Applicant:
This form (Page 1 & 2) MUST have all applicable information to avoid delays.
Date of Application _____/_____/_____ Tax Folio # _________-____-_________ P.R.A. # ______-___________
Owner’s Name: _______________________________________________Phone #(______)_______-_________
Owner’s Address: _________________________________City _____________________State ___Zip________
Fee Simple Titleholder’s Name (if other than Owner):________________________________________________
Fee Simple Titleholder’s Address: __________________________City_______________ State ___Zip________
Contractor: __________________________________________________ Phone #(______)_______-_________
Certificate of Competency #: ___________________State Registration # (if applicable): ____________________
Contractor’s Address: _________________________________City__________________ State___Zip ________
Job Name & Description of Work ________________________________________________________________
Job Address ________________________________________________________________________________
Subdivision ___________________________________________________________Block_______ Lot _______
Bonding Company ___________________________________________________________________________
Bonding Company Address______________________________City_________________State___Zip ________
Engineer_________________________________Registration #____________Phone (_____) _____ - ________
Engineer Address______________________________________City_________________State ___Zip _______
Architect _________________________________Registration #___________ Phone (_____) _____ - ________
Architect Address_____________________________________City_________________State ___ Zip ________
Mortgage Lender’s Name______________________________________________________________________
Mortgage Lender’s Address_____________________________ City _________________State ___ Zip _______
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 WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT
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 the City of Pompano Beach. I understand that a separate permit must be secured for
ELECTRICAL
WORK, PLUMBING, SIGN, WELLS, POOLS, FURNACES, BOILERS, HEATERS TANKS and AIR CONDITIONERS etc.
Owner Affidavit: I certify that all the forgoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
Signature of Legal Owner/Agent:
Signature of Legal Contractor:
(Including Contractor with notarized statement)
X
X
____________________________________________________
______________________________________________________
STATE OF FLORIDA - COUNTY OF BROWARD
STATE OF FLORIDA - COUNTY OF BROWARD
Sworn to (or affirmed) and subscribed before me
Sworn to (or affirmed) and subscribed before me
this_______ day of ___________________________, 20______ by
this_______ day of __________________________, 20_______ by
______________________________________________________
_______________________________________________________
(
(Type / Print Owner’s Name)
Type / Print Contractor’s Name)
______________________________________________________
______________________________________________________
NOTARY’S SIGNATURE
NOTARY’S SIGNATURE
as to Owner or Agent’s Signature
as to Contractor’s Signature
Name & Title (printed) ____________________________________
Name & Title (printed) ____________________________________
(Type / Print Notary’s Name)
(Type / Print Notary’s Name)
Personally Known _____ or Produced Identification ______
Personally Known _____ or Produced Identification ______
Type of Identification Produced ____________________________
Type of Identification Produced ____________________________
g/bldg/app/bldg.prmt.app
Effective Date: 1-1-91 - per F.S. 713.135(6)
Revised 10/ 7 /04
Page 1 of 2
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