BLD_Private_Provider_Plan_Compliance

Form # 9B-3.053-2002-02
Private Provider
Plan Compliance Affidavit
Effective January 20, 2003

Private Provider Firm

Private Provider

Address

Phone

phoneFormat: (000) 000-0000.

Fax

Email

example@example.com

I hereby certify that to the best of my knowledge and belief the plans submitted were reviewed for and are in compliance with the Florida Building Code and all local amendments to the Florida Building Code by the following affiant, who is duly authorized to perform plans review pursuant to Section 553.791, Florida Statute and holds the appropriate license or certificate:

Name

Plan Sheets

Florida License/Registration/Certification number and description

Signature of Reviewer:

SWORN AND SUBSCRIBED before me by

being personally known to mehaving produced as identification

Identification

and who being fully sworn and cautioned, state
that the foregoing is true and correct to the best of his/her knowledge or belief.

Signature of Notary:

Print Name

Notary Public: NOTARY STAMP BELOW

My commission expires