Form Ab-279 - Fort Lauderdale Permit Application Form
ADVERTISEMENT
1
2CITY OF FORT LAUDERDALE
CITY OF FORT LAUDERDALE
PERMIT APPLICATION
PERMIT APPLICATION
CITY OF FORT LAUDERDALE
PERMIT APPLICATION
CITY OF FORT LAUDERDALE
PERMIT APPLICATION
700 NW 19
700 NW 19
Avenue, Fort Lauderdale FL 33311
Avenue, Fort Lauderdale FL 33311
th
th
CITY OF
700 NW 19
Avenue, Fort Lauderdale FL 33311
th
FO RT LAUDERDALE
700 NW 19
Avenue, Fort Lauderdale FL 33311
th
700 N.W. 19th Avenue, Fort Lauderdale, Florida 33311
Permit Type: ________________________ Master Permit # ___________________________ Sub Permit #___________________________
Permit Type: ________________________ Master Permit # ___________________________ Sub Permit #___________________________
Permit Type: ________________________ Master Permit # ___________________________ Sub Permit #___________________________
Permit Type: _______________________ Master Permit # ___________________________ Sub Permit #___________________________
AFFORDABLE HOUSING
AFFORDABLE HOUSING
HOUSING AUTHORITY
HOUSING AUTHORITY
HABITAT FOR HUMANITY
HABITAT FOR HUMANITY
AFFORDABLE HOUSING
HOUSING AUTHORITY
HABITAT FOR HUMANITY
AFFORDABLE HOUSING
HOUSING AUTHORITY
HABITAT FOR HUMANITY
BLACK INK -
BLACK INK -
COMPLETE FORM IN
COMPLETE FORM IN
BLACK INK -
ONLY SIGNATURES MAY BE IN STANDARD BLUE INK
ONLY SIGNATURES MAY BE IN STANDARD BLUE INK
BLACK INK -
COMPLETE FORM IN
ONLY SIGNATURES MAY BE IN STANDARD BLUE INK
COMPLETE FORM IN
ONLY SIGNATURES MAY BE IN STANDARD BLUE INK
Owner’s Name _________________________________________________________ Phone # __________________________
Owner’s Name _________________________________________________________ Phone # __________________________
Owner’s Name _________________________________________________________ Phone # __________________________
Owner’s Name _________________________________________________________ Phone # __________________________
Owner’s Street Address ____________________________________________________________________________________
Owner’s Street Address ____________________________________________________________________________________
Owner’s Street Address ____________________________________________________________________________________
Owner’s Street Address ____________________________________________________________________________________
City ________________________________ State ______ Zip Code _________ Owner’s Email _________________________
City ________________________________ State ______ Zip Code _________ Owner’s Email _________________________
City ________________________________ State ______ Zip Code _________ Owner’s Email _________________________
City ________________________________ State ______ Zip Code _________ Owner’s Email _________________________
Fee Simple Titleholder’s Name (if other than owner) __________________________________________________________
Fee Simple Titleholder’s Name (if other than owner) __________________________________________________________
Fee Simple Titleholder’s Name (if other than owner) __________________________________________________________
Fee Simple Titleholder’s Name (if other than owner) __________________________________________________________
Fee Simple Titleholder’s Address ____________________________ City ____________________ State ______ Zip________
Fee Simple Titleholder’s Address ____________________________ City ____________________ State ______ Zip________
Fee Simple Titleholder’s Address ____________________________ City ____________________ State ______ Zip________
Fee Simple Titleholder’s Address ____________________________ City ____________________ State ______ Zip________
Contractor’s Company Name _____________________________________________ Phone # _______________________
Contractor’s Company Name _____________________________________________ Phone # _______________________
Contractor’s Company Name _____________________________________________ Phone # _______________________
Contractor’s Company Name _____________________________________________ Phone # _______________________
Contractor’s Business Address _______________________________ City ____________________ State _____ Zip _______
Contractor’s Business Address _______________________________ City ____________________ State _____ Zip _______
Contractor’s Business Address _______________________________ City ____________________ State _____ Zip _______
Contractor’s Business Address _______________________________ City ____________________ State _____ Zip _______
Contractor’s E-mail Address __________________________________________ Alternate Phone # ___________________
Contractor’s E-mail Address __________________________________________ Alternate Phone # ___________________
Contractor’s E-mail Address __________________________________________ Alternate Phone # ___________________
Contractor’s E-mail Address __________________________________________ Alternate Phone # ___________________
Qualifier’s Name _______________________________________________ State Certificate # _________________________
Qualifier’s Name _______________________________________________ State Certificate # _________________________
Qualifier’s Name _______________________________________________ State Certificate # _________________________
Qualifier’s Name _______________________________________________ State Certificate # ________________________ _
Broward County Certificate of Competency # ______________________ State Registration # ____________________
Broward County Certificate of Competency # ______________________ State Registration # ____________________
Broward County Certificate of Competency # ______________________ State Registration # ____________________
Broward County Certificate of Competency # ______________________ State Registration # ____________________
Job Address __________________________________________________ City ________________________________________
Job Address __________________________________________________ City ________________________________________
Job Address __________________________________________________ City ________________________________________
Job Address __________________________________________________ City ________________________________________
Legal Description: Subdivision ____________________________________ Lot _______ Block _______ Building # _______
Legal Description: Subdivision ____________________________________ Lot _______ Block _______ Building # _______
Legal Description: Subdivision ____________________________________ Lot _______ Block _______ Building # _______
Legal Description: Subdivision ____________________________________ Lot _______ Block _______ Building # _______
Type of Property:
Type of Property:
Single family
Single family
Duplex/Two-family
Duplex/Two-family
Multi-Family
Multi-Family
Condominium
Condominium
Commercial
Commercial
Type of Property:
Type of Property:
Single family
Single family
Duplex/Two-family
Duplex/Two-family
Multi-Family
Multi-Family
Condominium
Condominium
Commercial
Commercial
Description of Work to be Done _____________________________________________________________________________
Description of Work to be Done _____________________________________________________________________________
Description of Work to be Done _____________________________________________________________________________
Description of Work to be Done _____________________________________________________________________________
Type of Work:
Type of Work:
New
New
Addition
Addition
Alteration
Alteration
Demolition
Demolition
Repair
Repair
Revision
Revision
Other
Other
Type of Work:
New
Addition
Alteration
Demolition
Repair
Revision
Other
Type of Work:
New
Addition
Alteration
Demolition
Repair
Revision
Other
Square Feet ______________
Square Feet ______________
Linear Feet ___________
Linear Feet ___________
# Windows/Doors ___________
# Windows/Doors ___________
# Shutter Openings __________
# Shutter Openings __________
Square Feet ______________
Linear Feet ___________
# Windows/Doors ___________
# Shutter Openings __________
Square Feet ______________
Linear Feet ___________
# Windows/Doors ___________
# Shutter Openings __________
# Gallons ___________
# Gallons ___________
Max Cap ___________
Max Cap ___________
Present Use __________________________________________________________
Present Use __________________________________________________________
Total Job Cost:
$_____________
# Gallons ___________
Max Cap ___________
# Gallons ____ Max Cap ___________
Present Use __________________________________________________________
Present Use _______________________________
Total Job Cost:
Total Job Cost:
$_______________
$_______________
Building
Building
$_______________
$_______________
Engineering $________________
Engineering $________________
Total Job Cost:
$_______________
Building
$_______________
Engineering $________________
Electric
$_______________
Building
$_______________
Engineering $________________
Electric
Electric
$_______________
$_______________
Roof
Roof
$_______________
$_______________
Fence/Wall
Fence/Wall
$________________
$________________
Electric
$_______________
Roof
$_______________
Fence/Wall
$________________
Fire Sprinkler
$_______________
Roof
$_______________
Fence/Wall
$________________
Mechanical
Mechanical
$_______________
$_______________
Pool/Spa
Pool/Spa
$_______________
$_______________
Sign
Sign
$________________
$________________
Mechanical
$_______________
Pool/Spa
$_______________
Sign
$________________
Mechanical
$_______________
Pool/Spa
$_______________
Sign
$________________
Plumbing
Plumbing
$_______________
$_______________
Paving/deck $_______________
Paving/deck $_______________
Landscaping $ _______________
Landscaping $ _______________
Plumbing
Plumbing
$_______________
$_______________
Paving/deck $_______________
Paving/deck $_______________
Landscaping $ _______________
Landscape
$ _______________
_
_
For Office Use Only: Occupancy Type ________ Construction Type _______Lowest Floor Elevation ________ Flood Zone ______
For Office Use Only: Occupancy Type ________ Construction Type _______Lowest Floor Elevation ________ Flood Zone ______
_
_
For Office Use Only: Occupancy Type ________ Construction Type _______Lowest Floor Elevation ________ Flood Zone ______
For Office Use Only: Occupancy Type ________ Construction Type _______Lowest Floor Elevation ________ Flood Zone ______
Architect/Engineer _______________________________________ Reg. # _______________________ Phone #______________________
Architect/Engineer _______________________________________ Reg. # _______________________ Phone #______________________
Architect/Engineer _______________________________________ Reg. # _______________________ Phone #______________________
Architect/Engineer _______________________________________ Reg. # _______________________ Phone #______________________
Architect/Engineer Address__________________________________ City _____________________________ State _____ Zip __________
Architect/Engineer Address__________________________________ City _____________________________ State _____ Zip __________
Architect/Engineer Address__________________________________ City _____________________________ State _____ Zip __________
Architect/Engineer Address__________________________________ City _____________________________ State _____ Zip __________
Bonding Company _______________________________________ Address _____________________________________________________
Bonding Company _______________________________________ Address _____________________________________________________
Bonding Company _______________________________________ Address _____________________________________________________
Bonding Company _______________________________________ Address _____________________________________________________
Mortgage Lender ________________________________________ Address _____________________________________________________
Mortgage Lender ________________________________________ Address _____________________________________________________
Mortgage Lender ________________________________________ 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
Application is hereby made to obtain a permit to do the work and installation as indicated. I certify that no installation or work has
Application is hereby made to obtain a permit to do the work and installation as indicated. I certify that no installation or work has
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
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction
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
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
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
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,
must be secured for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, DRIVEWAYS,
must be secured for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, DRIVEWAYS,
must be secured for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, DRIVEWAYS,
ROOFS, ETC.
ROOFS, ETC.
ROOFS, ETC.
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
OWNER’S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
OWNER’S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
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
laws regulating construction and zoning. Furthermore, I authorize the above-named contractor to do the work stated
.
laws regulating construction and zoning. Furthermore, I authorize the above-named contractor to do the work stated
.
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
WARNING TO OWNER: Your failure to record a notice of commencement may result in your paying twice for improvements to your
WARNING TO OWNER: Your failure to record a notice of commencement may result in your paying twice for improvements to your
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
property. If you intend to obtain financing, consult your lender or an attorney before recording your notice of commencement. The notice
property. If you intend to obtain financing, consult your lender or an attorney before recording your notice of commencement. The notice
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.
of commencement must be recorded at the Broward County Clerk of the Courts, Room 114, 115 S Andrews Ave, Fort Lauderdale FL 33301.
of commencement must be recorded at the Broward County Clerk of the Courts, Room 114, 115 S Andrews Ave, Fort Lauderdale FL 33301.
of commencement must be recorded at the Broward County Clerk of the Courts, Room 114, 115 S Andrews Ave, Fort Lauderdale FL 33301.
STATE OF ____________COUNTY OF ________________________________
STATE OF ____________COUNTY OF ________________________________
STATE OF FLORIDA – COUNTY OF __________________________________
STATE OF FLORIDA – COUNTY OF __________________________________
STATE OF ____________COUNTY OF ________________________________
STATE OF FLORIDA – COUNTY OF __________________________________
STATE OF ____________COUNTY OF ________________________________
STATE OF FLORIDA – COUNTY OF __________________________________
Signature _______________________________________________________
Signature _______________________________________________________
Signature ________________________________________________________
Signature ________________________________________________________
Signature _______________________________________________________
Signature ________________________________________________________
Signature _______________________________________________________
Signature ________________________________________________________
Circle one: Owner or Agent
Circle one: Owner or Agent
Circle one: Contractor or Owner (with Owner Builder Affidavit)
Circle one: Contractor or Owner (with Owner Builder Affidavit)
Circle one: Owner or Agent
Circle one: Contractor or Owner (with Owner Builder Affidavit)
Circle one: Owner or Agent
Circle one: Contractor or Owner (with Owner Builder Affidavit)
Print Owner/Agent Name _______________________________________
Print Owner/Agent Name _______________________________________
Print Contractor/Owner Name ____________________________________
Print Contractor/Owner Name ____________________________________
Print Owner/Agent Name _______________________________________
Print Contractor/Owner Name ____________________________________
Print Owner/Agent Name _______________________________________
Print Contractor/Owner Name ____________________________________
Sworn to (or affirmed) and subscribed before me this_________ day
Sworn to (or affirmed) and subscribed before me this_________ day
Sworn to (or affirmed) and subscribed before me this __________ day
Sworn to (or affirmed) and subscribed before me this __________ day
Sworn to (or affirmed) and subscribed before me this_________ day
Sworn to (or affirmed) and subscribed before me this __________ day
Sworn to (or affirmed) and subscribed before me this_________ day
Sworn to (or affirmed) and subscribed before me this __________ day
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
of ______________________________, 20__________.
Signature______________________________________________________
Signature______________________________________________________
Signature_________________________________________________________
Signature_________________________________________________________
Signature______________________________________________________
Signature_________________________________________________________
Signature______________________________________________________
Signature_________________________________________________________
NOTARY as to Owner/Agent
NOTARY as to Owner/Agent
NOTARY as to Contractor/Owner
NOTARY as to Contractor/Owner
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NOTARY as to Owner/Agent
NOTARY as to Contractor/Owner
Print Notary Name _____________________________________________
Print Notary Name _____________________________________________
Print Notary Name ________________________________________________
Print Notary Name ________________________________________________
Print Notary Name _____________________________________________
Print Notary Name ________________________________________________
Print Notary Name _____________________________________________
Print Notary Name ________________________________________________
_______ Personally known or ______ Produced Identification
_______ Personally known or ______ Produced Identification
_______ Personally Known or _______ Produced Identification
_______ Personally Known or _______ Produced Identification
_______ Personally known or ______ Produced Identification
_______ Personally Known or _______ Produced Identification
_______ Personally known or ______ Produced Identification
_______ Personally Known or _______ Produced Identification
Type of Identification Produced ________________________________
Type of Identification Produced ________________________________
Type of Identification Produced ___________________________________
Type of Identification Produced ___________________________________
Type of Identification Produced ________________________________
Type of Identification Produced ___________________________________
Type of Identification Produced ________________________________
Type of Identification Produced ___________________________________
Notary Stamp:
Notary Stamp:
Notary Stamp:
Notary Stamp:
Notary Stamp:
Notary Stamp:
Notary Stamp:
Notary Stamp:
visit us at
visit us at
visit us at
FORM AA-279 Revised 8/20/13
FORM AA-279 Revised 5/02/11
FORM AA-279 Revised 5/02/11
8/20/13
visit us at
FORM AA-279 Revised 5/02/11
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