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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Co/' dC) Permit Number:
RECElv-.0 JUN 2 7 2017
� s
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:
Address:
Legal Description:
ropertyTax ID #: 3U1�a��°d$y d 53`db0'� Lot No.
Site Plan Name: Block No.
Project Name:
etbacks FrADON
Back: (S Right Side: 4-0- Left Side:1(,3
DETAILED OF WORK:
w on 1� ► ��
CONS tTION INFORMATION:
Additional work to be pertormed under this permit — check all that apply:
_Mechanical _ Gas Tank _ Gas Piping _ Shutters _ Windows/Doors
Electric _ Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction: — k1i d Sq. Ft. of First Floor:
Cost of Construction: $ 3S-D Utilities: —Sewer —Septic Building Height:
7Address:
�, �(� SJ Name:
Sb vc> - Company:
City: State: Address:
Zip Code: ' c► - Fax: City: State:
Phone No. '-7 i ' . Coa(o Zip Code: Fax:
E-Mail: Q\��SS0 s,_I(Y-)a L.0 0M 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.
AM
_ _ __ _ _
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORM "
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: _ Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone 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 your paying twice for
improvements to your property. A otice of Commencement must be recorded and posted on the jobsite
before the first inspection,. If you intend to obtain financing, consult with lender or an attorney before
commencing work or re rdin our Notice of Commencement.
��AAA'l
SikKAure of Owner/ L se tontractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA
COUNTY OF S-� -
COUNTY OF
The forgoing instrument was acknowledged before me
thisa l day of S-v..-t , 20]� by
The forgoing instrument was ackn ledged before me
this day of 20_ by
`N4n c V 1- Y -,A�A — C C 0 :S
(Name of per on ack owledging)
(Name of person ackn ledging )
(Signature of Notary Pub c- State of Florida)
(Signature of otary Public- State of Florida )
Personally Known OR Produced Identification
Personally nown OR Produced Identification
Type of Identif' ation
Produced L .t.Pey.''-. DEANNA MARIE GIVENS
MY COMMISSION # GG 02202
*` EXPIRE December 16.2020
Commission No. P::
of p�q r g�ru Notary Public undarwri
a of I entif1cation
p duc d
l mission No. (Seal)
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEA TURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
i `� I `
V
DATE
COMPLETED
ev.
RE�; �0 JUN 9- 7 117
� �
Planning & Development Services Department
Building & Code Regulations
2300 Virginia Avenue
Fort Pierce, Florida 34982
(772)462-1553
OWNER/BUILDER 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 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 appl' ble
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 tf) 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. (�
Initial �C
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 ft the
cost of the license. Initial
I understand that if any person that is unlicensed and uninsured gets injured on my construction pro ct-
they may be entitled to workmen's compensation. I could be held liable for all doctor, lawyer and related m Ie�j' al
cost, which could include loss of wages during recovery from their injury. Initial 01-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• hereby acknowledge that I have read and understand the above disclosure statement d that I further
understand that any violation of the terms of the owneribuilder exemption shall be rep ed by the Building and
Zoning Department to the Florida State Department of Professional Regulation. Signed d ac owledged on this
QV7 day of �U n� of 20 �. _
STATE OF FLORIDA
COUNTY OF
The foi+egoing instrument was acknowledged before me thisZA day of S V w, t , 20�_,
by 6�\ ty v w%— <. f o ss who is personally known to me, or who has
�prOducedL 1) L as identification.
Signature of No Type or Print Name of Nota
Public Commission Number DEANMENs
Title: No
�' '•,�': MY COMMISSION # GG 022023
EXPIRES: December 16, 2020
+; °=
SLCPDSD Revised 05/15/2014 .3,yF �,".•' Bonded Thrtr Notary Public Underwriters
0
RECE)I'^D JUN 2 7 2017
ST. LUCIE COUNTY
BUILDING & ZONING
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
772-462-1553
FILLED LANDS AFFIDAVIT
I, the undersigned, am the owner of the following described property:
Ist\0-Co01-0aS3-9M0-1
(Tax 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 11 t"59 I , I acknowledge that as owner of
the above described property, and in accordance with Section 7.04.01(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.
Property O r Name
STATE OF FLORIDA, COUNTY OF ` 1" V C
Property
Signature
7
ACKNOWLEDGED BEFORE ME THIS �� DAY OF Sy y1 � 20—a
WHO IS PERSONALLY KNOWN TOME OR WHO HAS PRODUCED
V AS IDENTIFICATION.
ti a, r v.
SIGNATURE OF NOTARY TYPE OR PRINT N
�w� P DEANNA MA!RIE GIVENS
` "P MY 96tG 022023
NOTARY PUBLIC TITLE L�ti' COMMI I Iv R EXPIRES: December 16, 2020
�� F o,".•' Bonded Thru Notary Public Underwriters