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t pIIER^ Department of Building & Community Response
P.O.Box 1480 e 100 North U.S. 1 •Fort Pierce,FL 34954
Phone: (772)467-3529 or(772)467-3724 a Fax: (772)467-3849
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"DEBRIS FORM"
OWNER / BUILDER OR CONTRACTOR AFFIDAVIT
Asper City Ordinances 16-22, 16-46, 16-48 and As a condition of obtaininiz any permit for
construction/repair or renovation:
Owner: City of Fort Fierce Housing Authority
Property Address: i3103 Avenue L, Fort Pierce, FL
Permit # Contractor: Black Street Enterprises, LLC
I understand and accept full responsibility for the prompt removal of all debris and
construction materials from the property for which I am seeking to obtain a building
permit in accordance with the Code of Ordinances of the City. Initials LD
I agree that no debris or construction materials will be placed on any public property
or on any public right-of-way except as may be specifically authorized by the Code of
Ordinances. Initials LD
I further understand that prior to a final inspection for the project completion or
issuance of a Certificate of Occupancy(or Certificate of Completion), all debris and
construction materials shall be removed from the property or the Inspector will not
approve the final inspection.Additional reinspection fees shall apply. Initials LD
I understand and accept full responsibility for debris removal at my own expense in
accordance with the City Code of Ordinances. Initials LD
I hereby acknowledge that I have read and understand the above statements and I further
understand that any violation of the terms of this affidavit shall be reported to the City of
Fort Pierce Department'of Building and Community Response for action and possible "stop-
work" order under the issued permit.
February 2, 2017
Date Contractor or Owner/Builder's Signature
It is the owner and contractor's responsibility to verify approval for any work through the Home Owner's Association
and/or Condominium Association,if applicable. The City will not be held responsible for disputes between Home
Owner's Association,Condominium Association,owner and/or contractor.
February 2, 2017
Date Contractor or Owner/Builder's Signature
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G drive/building/forms/Debris Affidavit
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