CONTRACTOR—PLEASE COMPLETE INFORMATION AND SIGN IN APPROPRIATE BLOCK BELOW. BY SIGNING BELOW, I HEREBY SWEAR THAT I AM IN COMPLIANCE WITH FLORIDA'S WORKER'S COMPENSATION LAW AND THAT I HAVE SECURED COVERAGE OR HAVE A VALID CERTIFICATE OF EXEMPTION.
Building Contractor:___
State/Cert/Reg #___
Address _____
City _____
State ___ Zip ___
Phone _____ Fax _____
State/Cert/Reg #
Cell _____Email: _____
M/H Set-up Contractor: _____
M/H Set-up Contractor:___
State/Cert/Reg #
Address _____
City _____
State ___ Zip ___
Phone _____ Fax _____
Cell _____ Email: _____
Signature ___ Signature ___
Plumb Contractor:___
State/Cert/Reg #___
Address___
City ___
State ___ Zip ___
Phone _____ Fax _____
State/Cert/Reg #_____
Cell _____ Email: _____
Address _____
HVAC Contractor:___(*)
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Address ___
City ___
State ___ Zip ___
Phone _____ Fax _____
Cell Email:
Signature _____ Signature _____
Elec. Contractor: ___
State/Cert/Reg #___
Address_____
City ___
State _____ Zip _____
State/Cert/Reg #_____
Phone _____ Fax _____
Address _____
Cell _____ Email: _____
City _____
LP Gas Contractor: ___
State/Cert/Reg #
Address _____
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State ___ Zip ___
Phone _____ Fax _____
Cell Email:
Signature ___ Signature ___
State/Cert/Reg#___ State/Cert/Reg#___
Address_____
City ___
State ___ Zip ___
State/Cert/Reg #_
Phone _____ Fax _____
Cell Email:
Signature _____
*NOTE TO HVAC CONTRACTOR: FLORIDA BUILDING CODE – ENERGY EFFICIENCY, REQUIRES THAT THE CONTRACTOR PROVIDE MANUAL J & MANUAL N ON ALL NEW CONSTRUCTION AND REPLACEMENT HVAC SYSTEMS; CONTRACTOR MUST ALSO PROVIDE CERTIFICATION THAT ALL DUCTWORK HAS BEEN INSPECTED AND ALL NECESSARY REPAIRS/TAPING HAVE BEEN COMPLETED.
Approved by ___ Date: ___
Permit Application Form – Dec 2020