Residential & Mobile Home Permit Application

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RESIDENTIAL & MOBILE HOME PERMIT APPLICATION

NON

-REFUNDABLE APPLICATION FEES DUE AT TIME OF SUBMITTAL / APPLICATIONS IN PENCIL WILL NOT BE ACCEPTED

REFERENCE # ________________________________________________

RSN#______________________________________

PROPERTY INFORMATION

Effective FBC 5th Edition 2014

EFFECTIVE CODE IS 2010 FBC

Tax Parcel Number (Short) ___________-_________-_________-____________ Long Parcel Number ________________________________________

Owner/Leaseholder’s Name______________________________________________________________ Day Phone #

__________________________________

Address

Cell Phone #

____________________________________________________________________________________

____________________________________

City

Fax #

__________________________________________________________ State____________ Zip_______________

______________________________________

E-Mail Address____________________________________________________________________________________________

Fee Simple Titleholder

Address

__________________________________________________

________________________________________________

(If other than owner)

City

State

Zip

___________________________________________________________________

________________________

_____________________

JOBSITE ADDRESS:

__________________________________________________________________________________________________________________

Number

Direction

Street Name

Type

Suite/Lot

City

County

Zip

__________________________________________________________________________________

_____________________

Legal Description (include Lot #)

___________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

DCA Modular [

]

Duplex [

]

Mobile Home [

]

Park Model / RV Perm Setup [

]

TYPE OF WORK PROPOSED:

(Check one)

Single Family Residence [

]

Townhouse [

]

Other (explain)_________________________________________________________________

New [

]

Replacement [

]

Check here if Owner/Contractor-Residence for own use & occupancy [

] - or- Is the Residential unit rental/lease property [

]

LICENSE CONTRACTOR INFORMATION:

Name of License Holder

License #

_________________________________________________________________

___________________________________________

Company Name

Phone #

_________________________________________________________________________________

__________________________________

Address

Mobile #

________________________________________________________________________________________

__________________________________

E-Mail Address for business use

___________________________________________________________________ Fax # ____________________________________

The standard method of notification is by e-mail, when available

Preferred Pick up location: Daytona Beach

DeLand

Private Provider Review: Yes___ No___ Private Provider Inspections: Yes___ No___

____

SUBCONTRACTORS: Enter license number for each subcontractor

Owner/Contractors must name a licensed Mobile Home Installer as a subcontractor

LICENSE #

CARD HOLDER’S NAME

LICENSE #

CARD HOLDER’S NAME

ELEC

PLUMB

____________________________ ________________________________

____________________________ ______________________________

HVAC

ROOF

___________________________ ________________________________

_____________________________ ______________________________

ARCH

ENG

___________________________ ________________________________

______________________________ ______________________________

OTHER

__________________________ ________________________________

___________________________ ______________________________

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.

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. 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 recording your Notice of Commencement. ** I hereby declare that all information contained in this building permit

application is true and correct*

Signature of Applicant__________________________________________________________________ Date_____________________

Check one: ______ Owner/Builder

Contractor or Authorized Agent

(Must personally appear in office & sign)

_______

(Agent must submit power of attorney)

STATE OF FLORIDA

COUNTY OF_

_________________________________

Affirmed and subscribed before me this

___________