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2. 
3. PRIVATE PROVIDER PLAN COMPLIANCE AFFIDAVIT
5. Process Number *
6. Address
8. Private Provider Firm:
9. Private Provider:
11. Address
13. City
14. State
15. Zip
17. Phone:
18. E-mail:
20. Notice -
    A private provider may only perform building code plan review services that are within the disciplines covered by that person’s licensure or certification. 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 hold the appropriate license or certificate.
22. Check all Disciplines that apply:*

    1. Building
    2. Structural
    3. Electrical
    4. Mechanical
    5. Plumbing
24. Plan Sheets
26. Florida Architect’s or Engineer’s Certification #:*
28. Name of Private Provider:*
29. Date
    Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field