HomeMy WebLinkAboutbergen gas app, contractAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
ST LuciE
UUNT-^Y
F O R 1 D A
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: Gas
PROPOSED IMPROVEMENT LOCATION:
Address: iuu,+ uelana Hvtrort tierce, FL 34951
Property Tax ID #: 1301-612-0190-000-4
Site Plan Name: Bergen Gas
Project Name:
DETAILED DESCRIPTION OF WORK: -
Lot No._
Block No.
/_,e 4a -t h to /12t_.) �j,Prl �E1 al r
New Electrical Meter Second Electrical Meter
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit– check all that apply:
_Mechanical _ Gas Tank Gas Piping _ Shutters
_ Electric _ Plumbing _ Sprinklers Generator
Total Sq. Ft of Construction:
Cost of Construction: $
Windows/Doors Pond
Sq. Ft. of First Floor:
Utilities: —Sewer —Septic
Roof Pitch
Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name William Bergen
Name: Michael Flaxman
Address:7004 Deland AVE
Company: Energized Electric
City.. Fort Pierce State: _
Zip Code: 34951 Fax:
Phone No. 8136136333
Address:4252 Bandy Blvd
City: FT pierce State: FL
Zip Code: 34981 Fax:
Phone No 7724661095
E-Mail:Wildive117@aol.com
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
If.
E -Mail energizedgenerators@gmail.com
State or County License 1_145030
,, a 11—wn"CU ivvut,e u, %-ummencemerix IS required.
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
MORTGAGE COMPANY: Not Applicable
Name:
_
Name:
Address:
Address:
City: State:
Zip: Phone
City: State:
FRONT
Zip: Phone:
FEE SIMPLE TITLE HOLDER: — Not Applicable
BONDING COMPANY: Not Applicable
Name:
Name:
Address:
Address:
City:
City:
Zip: Phone:
Zip: Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in accordance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review: room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
WARNING TO OWNER: Your failure to Record a Notice of Commencement may result in paying twice for
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie County and posted on the jobsite efore the first inspection. If you intend t btain financing, consult
with lender or an attorney bei mepcing work or recording your Notice -of Commencement.
Signature of Owner/
STATE OF FLORIDA
COUNTY OF
r as Agent for Owner
—, r
Sworn to (or affirmed) and subscribed before me of
Physical Pre a ce..or Online Notarization
th (&y of 1 2020 by
AU V)
Name of person making stat ment.
Personally Known OR Produced Identification
Type of Identification
Pro,duced n
(Signa. red :I #ary PWIEfJ�Gf CaRtlGl ida )
MY COMMISSION # GG 232946
Commi fC
Q EXPIRES: June 2i, 2022 (Sea
Bonded T ru o u Iic Under0ters
REVIEWS
FRONT
ZONING
COUNTER
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Signat7urebf96ntractor/License Holder
STATE OF FLORID
COUNTY OF
'rn to (or affirmed) and subscribed before me of
P-bysrcal Preynce or Online Notarization
this day of �°)i/'�61 , 2020 by
P_
I W 111 0
Name of person making s atement.
Personally Known OR Produced Identification
Type of Identification
Pr dt ced
(S
14,P COM `MISSIO� VNI.ALVE'S
N # GC 23294Q lea])
SUPERVISORPLANS I VEGETATION I IIATREV RILE MREV ROVE
REVIEW REVIEW REVIEW
*Treasure Coast 772-466-1093, 4252 Bandy Blvd, Fart fierce, FL, 34931_ Fax 772-318-6672*
°'Falx Beach 561-752-0214, 1700 Latham Ted, Suite 2, West balm Beach, FL, 33409
William Bergen
7004 Deland Ave
Fort Pierce, FL 34951
813-613-6333
Wildivell7@aol.com
June 25, 2020
1) Supply and install aboveground gas line to generator and final connect
2) Price includes all lca,�bf'or, material and permits
NOTE: Gas line to be installed by Thompson Gas
For the sum oh
1786 SW Biltmore St, Port ST Lucie, FL, 34984 *Licensed & Insured FL34747
Toll Free 855-PROGAS4 *Treasure Coast 772-777-8133 *Palm Beach 561-752-0214 *Fax 772-318-6673
Charges & Payments: Charges are due in full at time services are rendered unless otherwise stated below. Contractor may
charge and customer agrees to pay a late fee for all past due payments, such fees not to exceed the maximum allowed rate by
applicable law. Customer shall be responsible and agrees to pay for all charges billed, applicable taxes, applicable legal fees and
other charges/fees.
P op sal/Contract pricing good for 30 clays from Proposal/Contract slate
®"1*74��S dueCompletion
Vitt! appreciate me opportunity you 17ave extended us to quote on this work and would
like to thank you in advance for your consideration.
Authorized signature:
Acceptance of Proposal
I, r' + eft-' e tJ (printed name), authorize Energized Gas to
complete the work in acro ance with the above specifications and conditions. I agree to pay as per
terms outlined above.
Signature
Date n/ k�-70
This agreement shall be construed under the laws of the State of Florida. This agreement contains the entire understanding of the
parties and supersedes all previous verbal or written agreements: there are no other agreements, representations or warranties not
set forth herein. If any conflicts exist in this agreement between terms which are printed and those which are typed or written, the
typed or written language shall govern.
Page 2 of 2
CONTRACT TERMS AND CONDITIONS
Installation will comply with all local and state regulations and be consistent with standard industry code.
Installer is not responsible for landscaping repairs as a result of installation*. This includes but is not
limited to; damaged/broken sprinkler lines and/or damaged/broken water or sewer lines.
This contract price does NOT include bonding gas lines, converting outlets, converting appliances or
carbon monoxide detectors
Additional charges may apply if rock and/or roots are encountered during the excavation process.
Deposit will be forfeited if customer cancels after the permit process is initiated.
Customer is responsible for obtaining HOA/POA approval. Installer is not responsible for customers failing
to obtain final approval.
If home is located in flood zone, the additional cost will be the responsibility of the homeowner if a tank tie
down, or buoyancy pad is required per the building department
A site survey of your property showing all property lines is required to pull a permit and can be submitted
along with this signed proposal.
*To include sod replacement a charge of $395 applies.
CUSTOMER SIGNATURE FOR ACKNOWLEDGMENT OF ABOVE TERMS
PRINTED NAME
SIGNATURE
7//
DAirE
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