Chicago, IL · Cook County
Applicant Acknowledgement and Hold Harmless
This form records a permit applicant’s acknowledgement of the Self-Certification Permit Program terms and agreement to hold the City harmless.
What this form is
The form is required for each permit application submitted under the City’s Self-Certification Permit Program. It asks the applicant or authorized representative to acknowledge the program terms and confirm details about the permit application; it also includes a hold harmless agreement for the applicant and/or property owner. The form provides fields for the project address, permit number, signer role, signature, printed name, and date.
Who needs it
Permit applicants under the Self-Certification Permit Program, or their named representatives, must complete the acknowledgement; an authorized tenant may complete the hold harmless agreement.
How to submit it
Complete the form and upload it to the Documents folder in ProjectDox for each permit application submitted under the Self-Certification Permit Program.
About notarization
This document is signed without a notary; it includes signature and date fields, and the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download Form 411 for the Self-Certification Permit Program.
- 2
Complete The Form
Enter the project address and permit application number, complete the applicable sections, and provide the signer’s role, signature, printed name, and date.
- 3
Check The Form
Review the completed form and make sure required fields are filled in.
- 4
Upload To ProjectDox
Upload the completed form to the Documents folder in ProjectDox for the permit application.
Frequently asked questions
- Who completes Form 411?
- The permit applicant or the applicant’s representative named on Page 5 of the Building Permit Application completes the acknowledgement. An authorized tenant or tenant representative may complete the hold harmless agreement.
- How do I submit Form 411?
- Upload the completed form to the Documents folder in ProjectDox for each permit application submitted under the Self-Certification Permit Program.
- Do I need a notary for the Applicant Acknowledgement and Hold Harmless?
- No. This document is signed without a notary; it includes signature and date fields, and the signer just signs and dates it.
Need something notarized?
This Applicant Acknowledgement and Hold Harmless doesn’t need a notary — but Illinois residents can notarize other documents online with a commissioned online notary.