City of Fort Lauderdale Permit Application
700 NW 19th Avenue, Fort Lauderdale FL 33311
Date: _________________________ Job Address ______________________________________________
Permit Type: _______________ Master Permit # _________________ Sub Permit # ________________
NOTE TO APPLICANT: THIS FORM MUST HAVE ALL APPLICABLE INFORMATION TO AVOID DELAYS.
USE BLACK INK ONLY.
Owner’s Name _________________________________________________________ Phone # __________________________
Owner’s Address __________________________________________ City _____________________ State _____ Zip ________
Owner’s E-mail Address ____________________________________________________________________________________
Company Name _______________________________________________________ Phone # __________________________
Company Address ________________________________________ City _____________________ State _____ Zip ________
Company E-mail Address ______________________________________________ Alternate Phone # __________________
Qualifier’s Name _______________________________________________ State Certificate # _________________________
Broward County Certificate of Competency # ______________________ State Registration # ____________________
Description of Work ________________________________________________________________________________________
Job Address ________________________________________________________ Present Use ___________________________
Subdivision __________________________________________________________Lot _______ Block _______ Zoning _______
Square Feet _______________ Linear Feet _______________ Max Cap _______________
Job Costs by Permit Type: Landscaping $_______________
Building $_______________ Fence/Wall $_______________ Mechanical $_______________
Paving/Deck $_______________ Electric $_______________ Plumbing $_______________
Roof $_______________ Pool/Spa $_______________ Sign $_______________
Occu. Type ____________ Construction Type ____________ Lowest Floor Elev. ____________ Flood Zone __________
Bonding Company _________________________________________________________________________________________
Bonding Company Address ____________________________ City_________________________ State _____ Zip ________
Engineer ______________________________________________ Reg. # ______________________ Phone ________________
Engineer’s Address ____________________________________ City ________________________ State _____ Zip ________
Architect _____________________________________________ Reg. # _____________________ Phone ________________
Architect’s Address____________________________________ City ________________________ State _____ Zip ________
Mortgage Lender __________________________________________________________________________________________
Mortgage Lender’s Address ____________________________ City _________________________ State ____ Zip ________
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 in the City of Fort Lauderdale. I understand that a separate permit must be secured for ELECTRICAL,
PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, DRIVEWAYS, 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 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 (a.k.a. Mechanics Lien Law) may result in
your paying twice for building improvements to your 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, Records Section, Room 114, 115 South Andrews Avenue, Fort Lauderdale FL 33301.
Signature ___________________________________________ Signature ___________________________________________
Owner or Agent Contractor
Date: ______________________________________________ Date _______________________________________________
____________________________________________________ ____________________________________________________
State of Florida Notary Public (FS 117.05.3.a) as to Owner or Agent State of Florida Notary Public (FS 117.05.3.a) as to Owner or Agent
My Commission Expires _____________________________ My Commission Expires ______________________________
--------------------------------- OFFICE USE ONLY: DO NOT WRITE BELOW THIS LINE -------------------------------------
Complaint # ______________________________ Inspector: ______________________________________________________
Authorization_______________________________________________________________________________________________
FORM AA-279 Revised 3/10/2009 Visit Us at www.fortlauderdale.gov
