GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
DEPARTMENT OF PLANNING AND NATURAL RESOURCES 
DIVISION OF PERMITS 
STX DISTRICT TEL: (340) 773-1082   STT/STJ DISTRICT TEL: (340) 774-3320 
    CERTIFICATE OF USE AND OCCUPANCY INSPECTION REQUEST 
Date: 
Contact/Phone Number: 
   (Please Print Clearly) 
LOCATION OF WORK:   
OWNER(S) NAME:   
(CHECK ONE OF THE FOLLOWING)  ☐ Residential  ☐ Commercial  ☐ Other 
Scope of Project:   
_ 
___________________________________________________________________________________________________ 
Building Permit No. 
Approved Date 
Mechanical Permit No. 
Approved Date 
Electrical Permit No. 
Approved Date 
Demolition Permit No. 
Approved Date 
Plumbing Permit No. 
Approved Date 
Flood Permit No. 
Approved Date 
The Construction work has been done under the supervision of the following: 
Owner’s Name: 
 Signature: 
Designer’s Name: 
 Signature: 
Contractor’s Name: 
 Signature: _ 
DEPARTMENTAL USE ONLY 
No. of Stories: 
Type of Wall: 
Type of Roof: 
 
Type of Floor:   
No. of Bedroom(s): 
 
No. of Bathroom(s): 
Smoke Detector(s):   
List additional interior rooms: ___________________________________________________________________ 
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
List additional exterior rooms:___________________________________________________________________ 
____________________________________________________________________________________________ 
Inspected By: _________________________________________ Date: __________________________________ 
Remarks: ____________________________________________________________________________________ 
SIGN
SIGN
SIGN
Certificate of Use and Occupancy 
Page 2 OF 2 
CERTIFICATION OF SUPERVISION 
UPON APPLICATION FOR A CERTIFICATE OF USE AND/OR OCCUPANCY. 
TO: 
 The Commissioner of Planning & Natural Resources 
(Through the Division of Permits) 
FROM: 
Certifying Building Supervisor of construction mentioned below 
SUBJECT: 
CERTIFICATION OF SUPERVISION AND TRADE WORKMANSHIP 
LEGAL DESCRIPTION 
NAME OF OWNER: 
  LOCATION OF BUILDING: 
BUILDING PERMIT NUMBER: 
DATE ISSUED: 
NAME OF DESIGNER: 
TITLE: 
(Print) 
I hereby certify that the above-mentioned project has been built under my supervision and that in its 
construction all the provisions of the V.I. Building Code and all other applicable laws are complied with. Also, 
pursuant to V.I. Code, Title 29, Chapter 5, §294 (c) and §298 (b) the work done is in compliance with the work 
proposed on said Building Permit. 
NAME OF CERTIFYING SUPERVISOR: 
Signature: 
Date: 
Certifying Supervisor 
SIGN