HomeMy WebLinkAboutOwner Builder Affidavit All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: �10�• 033
s r
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
PERMIT APPLICATION FOR:
PRG1P®SED INPROVEMENI' LOCATIO
Address: /2/?Q 1L0 � ! �iq'/l� D r ICO V, t e,rC
Legal Description:
Property Tax ID#: a rW- ca Q039, 000,7- Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: ✓ Right Side: Left Side:
�E�AI!LED DE�SGR'("PTION @F 1N®RaK:
C(+O'NSTRUCTION lNF®RII%IATRS
Additional work to be performed under this permit-check all that appy:
_Mechanical _Gas Tank _Gas Piping _Shutters i Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —Sewer —Septic Building Height:
0IINWER/LE=SS E: CONTRA OR:
NameC /(?_(T?-I C-> CCe C)t,1(S Name:
Address: 192,0 / PAI M pr Company:
City: R>',- State:_ Address:
Zip Code: 3 y 07 Fax: City: State:
Phone No. 56) -3-6(f 75 27 Zip Code: Fax:
E-Mail: Phone No
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
Planning&Development Services Department
COUNTYBuilding&Code Regulations
• 2300 Virginia Avenue
Fort Pierce,Florida 34982
(772)462-1553
OWNERBUILDER AFFIDAVIT DISCLOSURE STATEMENT
F.S.489.103(7)EXEMPTIONS
State law requires construction to be done by licensed contractors. You have applied for a permit under an
exemption to that law. The exemption allows you,as the owner of your property,to act as your own contractor even
though you do not have a license. You must provide direct, on-site supervision of the construction yourself. You
may build or improve farm outbuildings, a one-family or two-family residence for your use and occupancy. You
may also build or improve a commercial building at a cost not exceeding $75,000.00 as long as it is for your own
use or occupancy.You may not build or improve said structures for the purposes of selling or leasing that building.
If you sell or lease a building you have built or improved within one year after construction is complete, then a
presumption is created that it was built or improved for sale or lease, which is a violation of this exemption. You,
may not hire an unlicensed person to act as your contractor or to supervise people working on',your building; it is
your responsibility to make sure that people employed by you have licenses requited by.state law and by county or
municipal licensing ordinances. You may not delegate the responsibility for supervising work to a licensed
contractor who is not licensed to perform the work being done. Your construction must comply with all applicable
laws,ordinances,building codes,and zoning regulations. Initial -�-�
I understand that the building official and inspectors are not there to design or give advice on how to meet
the minimum code. Initial a
I understand that as an owner-builder that any contract disputes with sub-contractors and I must be handled
in a civil court with the advice of an attorney. This department will not mitigate any contract disputes.
Initial
I understand that if I compensate any person or company for work performed they are required to be
licensed in this jurisdiction. If for some reason they do not possess a license,I may be responsible and liable for the
cost of the license. Initial a �
I understand that if any person that is unlicensed and uninsured gets injured on my construction project-
they may be entitled to workmen's compensation. I could be held liable for all doctor, lawyer and related medical
cost,which could include loss of wages during recovery from their injury. . , Initial R I
To qualify for this exemption under this subsection,an owner must personally appear and sign the building
permit application and initial the above.
i
I hereby acknowledge that I have read and understand the above disclosure statement and that I further
understand that any violation of the terms of the owner/builder exemption shall be reported by the Building and
Zoning Department to the Florida State Department of Professional Regulation. Signed and acknowledged on this
day of -of 20
Owner/Builder-Signature
STATE OF FLORID
COUNTY OF �
The foregoing instrument was acknowledged before me this W day of ,20�,
by t)cL c.6 W_, tRwra. Loy:.— who is personally knowTO to me,or who has
oduced r�...` films as identification.
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Q-WgnaNure of Notary Type or Print Name of Notary " (Seal)
Title:Notary Public Commission Number �,�,�y�euoiaeN g6no�g� 'P -
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