HomeMy WebLinkAboutBuilding Permit Application PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
e �
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR,SUBCONTRACTOR OR CANCELLATION OF PERMT
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR—Change of Contractor is to be signed and notarized by the property owner,
and the new contractor of record for the current permit. A new permit application must also be completed with new
contractor information and signature. A new Notice of Commencement must be filed in the new contractor's name
for job values greater than $2,500 ($7,500 if A/C Change-out). A recorded copy must be submitted prior to
commencing any work There is a$50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR—Subcontractor changes are to be completed by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. There is a$50.00 fee for the Change of Sub-
Contractor.
CANCELLATION OF PERNUT—The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: C Permit Number: C73rJ�
Site Address: k C7O�
Qlk)Mn aIA \N� Mft)D(J)\JDState License SLC License
Original GC,subcontractor or owner/builder
TkState License SLC License
New G ,subcontractor \
Reason for Cancellation 0
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and employees from all
costs,fees or damages arising from any and all claims of action for any reason,which may arise as a result of this change of
con ctor/subcontractor-or c ellation of permit.A permit cannot be cancelled if work has been performed.
NAT9K O (o ed wilder) SIGNATURE GENERAL CONTRACTOR(or new GC,as applicable)
PRINT NAME PRINT NAME
State of Florida,County of St.Lucie County State of Florida,County of St_Lucie County
The following in mt vap acknowledged before me this The following instrument was acknowledged before me this
day of 1 ,200 t,by day of .20_,by
who is personally known to me who is personally known to
or o h roduced me or who has produced as ID.
Signa a of Notary Date Signature of Notary Date
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All APPLIPABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: ` 1 Permit Number:� �� �q
RECEIVED
Building Permit Application APR - 6 2021
Planning and Development Services Permitting Department
Building and Code Regulation Division Commercial Residential le County
2300 Virginia Avenue,Fort Pierce FL 34982
Phone:(772)462-1553 Fax:(772)462-1578
PERMIT APPLICATION FOR:
PRl�POSED IMPROVEMENT LOCATION „ „
Address: 65�t
Properly Tax ID#: L Lot No.
Site Plan Name: Block No.
Project Name:
R „
DETAILED pSCRPTtON Ot111ldK
4
:XR;.
New Electrical Meter Second Electrical Meter
$CONSTRtJCT101`lNFORMATION "
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Additional work to be performed under this permit—check all that apply:
Mechanical _Gas Tank —Gas Piping _Shutters Windows/Doors _Pond
Electric _Plumbing _Sprinklers _Generator X_Roof Pitch
Total Sq.Ft of Construction: Sq. Ft. of First Floor: "'Van
Cost of Construction:$ Utilities: —Sewer —Septic Building Height:
OWNER/LESSEE' R ;;; `y COIVTRA'CTOR
Name alpwoe Name:
Addres 0 (�� -� Com ny:
City: vwvce, State: dre s:
Zip Code:2 K Fax: City: State:
Phone No. � J 14 dZT1314 Zip d Fax: )�
E-Mail: S Phone lyo
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.
If value of HAVC is$7,500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTgLCONSTRUCTION LIEN LAW INFORMATION
f:
DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLEHOLDER: _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 before the first inspection. If you intend to obtain financing, consult
with lender or an attorney before commencing work or recording our Notice of Commencement.
na re of Owner/`L a ontractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLOR STATE OF FLORIDA
COUNTY OF C COUNTY OF
Swqfn to(or affl ed)and subscribed before me of Sworn to(or affirmed)and subscribed before me of
�� Ph sical Pre nce pr Online Notarization Physical Presence or Online Notarization
this day of 2024 by this day of 2020 by
Name f pers making sta emen . Name of person making statement.
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identifica n Type of Identification
Produced L Produced
e-4�a I i_AA
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(Signatut of Notary (Signature of Notary Public-State of Florida)
" Y P,
;af� ,i,a KAREN S. NIELSEN
Commission No. =; �,State of 51��iq-Notary Public Commission No. (Seal)
ommi ion 9l 00 207484
��iOF ftO;O�` MY Commission Expires
June
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.
Situ LlLuL - �
Planning&Development Services Department
Building&Code Regulations
2300 Virginia Avenue
Fort Pierce,Florida 34982
(772)462-1553
OWNERIBUILDER 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.
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.
Initial Here,Qc-5-
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.
Initial Here. e�
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 Here.
I understand that the building official and inspectors are not there to design or give advice on how to meet the
minimum code. Initial Here.c-r
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 Here.5CS'
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 Here.fE!)CS
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.Here.�'�
To qualify for this exemption under this subsection, an owner must personally appear, 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 Zoning
Dep n to the Florida State Department of Professional Regulation. igned and ackno%Pledged n thi _
day of t of 20M
e udder Sagna
STATE OF FLO
Co
Y OF
The f r oin instrurpent acknow Iced before me this 0 day of r I ,20- I ,
by 1� who is personally known to me,or who has
produced as identification.
Signature of Notary Type or Print Name of Notary (Seal)
Title.Notary Public
L
"KKA`R,FN S. NIELSEN
Public
Commission # GG 207484
My Commission Expires
June 12, 2022