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PLANNING&DEVELOPMENT SERVICES DEPARTMENT
Building&Code Regulations Division
2300 VIRGINIA AVENUE
FORT PIERCE,FL 34982-5652
(772)462-1553
FILLED LAND AFFIDAVIT
I I,the undersigned, am the owner of the following described property,
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(Parcel Id#/Legal description/Address)•
for which I have applied to 'St. Lucie County for a Final Development Permit. In
accepting this Final Development Permit, BP Number , I acknowledge
that as owner of the above' described property, and in accordance with Section
7.O4.O1(D), St.Lucie County Land Development Code,I shall be responsible for assuring
adequate drainage so that the immediate community WILL NOT be adversely affected.
I further acknowledge that in granting this permit for the development of this property,
St. Lucie County is neither obliged nor liable to provide for, or maintain in any form,
adequate drainage off my property which will not adversely affect the immediate
community.
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Property Owner Name(Please Print)
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Property Owner Signature Date
STATE OF FLORIDA,COUNTY OP,2k*
ACKNOWLEDGED BEFORE ME THIS ��• DAY OF 20�
By1�� A SYVHO IS PERSONALLY KNOWN TO ME(a OR WHO HAS
PRODUCED 71UAV dr, \✓C—► AS IDENTIFICATION.
t�.ma's
SIGNATURE OF NOT Y PUBLIC T OR PRINT NOTARY
COMMISSION NUMBER
(SEAL)
i
SLCPDSD Revised 04/11/2011
` Y`Ti AUDREY
B.HUMPHREY
*= MY COMMISSION b FF 174
Via,: EXPIRES:March 6,.20192
9f,F 6o'ed Th-Wotan Public Unde.,,,s
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Planning&Development Services Department
{ Jab Building&Code Regulations
2300 Virginia Avenue
Fort Pierce,Florida 34982
(712)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 itis 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 required 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^V H
I understand that the building official and inspectors are not there to design or give advice on how to meet
the minimum code. Initial
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. f!
Initial L✓1n
f 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
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 ocould be held liable for all doctor, lawyer and related medical
cost,which could include loss of wages during recovery from their injury. Initial W
To qualify for this exemption under this subsection,an owner must personally,appear and sign the building
permit application and initial the above.
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 ownerlbuilder exemption shall be reported by the Building and
Zgnling Departnt to the Florida State Department of Professional Regulation. Signed and acknowledged on this
_g day of of 20�.
Owner/Builder Signature
STATE OF FLORI
COUNTY OF
The foregoing instrument 1rs1 ackn wledged before me this day o ,20�,
by M'U I who is personally known to me,or who has
produced J as identification.
Signature of Nota
���;TypVePrint Name of Notary (Seal)
Title:Notary Public Commission Number
SLCPDSD Revised 05/15/2014
AUDREY B.HUMPHREY
MY COMMISSION li FF 174772
• : EXPIRES:March 6,2019
Bonded Thru Notary Pubric Underwr tens
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