HomeMy WebLinkAboutPermit ApplicationDocuSign Envelope ID: 916AC33A-FB7B-4BDE-AC6A-D62088D43FFB
_ PLANNING & DEVELOPMENT SERVICES
- Building & Code Compliance Division
COUNTY
- BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
ERICSSON INC - FRANK KISEL
(Company Name/Individual Name)
the ELECTRICAL SUB
(Type of Trade)
have agreed to be
Sub -contractor for ERICSSON INC - STEVE NICHOLS
(Primary Contractor)
For the project located at 6189 N US-1, ST LUCIE COUNTY, FL
(Project Street Address or Property Tax ID #)
It is understood that, if there is any change of status regarding our participation with the above mentioned
project, the Building and Code Regulation Division of St. Lucie County will be advised pursuant to the
filing of a Change of Sub -contractor notice.
D�ned by:
� 1�SIGNATURE (Qualifier)
STEVE NICHOLS
PRINT NAME
CGC1518237
COUNTY CERTIFICATION NUMBER
State of Florida, County ofSeminole
The foregoing instrument was signed before me this 5 day of
May 2021, by Steve Nichols
who is personally known A/or has produced a
as identification.
DocuSigned by:
Signature of No J7445U7F_.
0acu5igned by:
SUB-C NTRACTOR SIGNATURE (Qualifier)
FRANK KISEL
PRINT NAME
EC13009490
COUNTY CERTIFICATION NUMBER
State of Florida, County of Seminole
The foregoing instrument was signed before me this 5 day of
May 2021 by Frank Kisel
who is personally known Vor has produced a
as identification.
Docu Sig ned by:
STAMP
MdarwW Nh*Ary Public
Evan Wong
Print Name of Notary I'iblic
EVAN DAVID WONG
Notary Public -State of Florida
Commission # GG 350394
Commission Expires 7/1/2023
Revised 11/16/2016
Evan Wong
Print Name of Notary Public
EVAN DAVID WONG
Notary Public -State of Florida
Commission # GG 350394
Commission Expires 7/1/2023
STAMP
DocuSign Envelope ID: 3D700442-Al2C-419B-BCAE-OB7D1568DF4C
All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
L UME
Building Permit Application
Planning and Development Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:TELECOMMUNICATION ANTENNAS
PROPOSED IMPROVEMENT LOCATION:
Address: 6189 N US -1
Property Tax ID #. 1406-413-0003-000-8 Lot No.
Site Plan Name: Block No.
Project Name: T-MOBILE A2P0045B
DETAILED DESCRIPTION OF WORK:
REMOVE ALL EXSITING T-MOBILE TELECOMM EQUIPMENT ON THE TOWER AND THE GROUND.
INSTALL 2 NEW CABINETS ON THE GROUND. 6 NEW ANTENNAS, 9 NEW RRU, 3 HYBRID CABLE, 3 NEW MOUNTS.
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 _ Windows/Doors _ Pond
Electric _ Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $ 35000 Utilities: —Sewer _Septic Building Height:
OWN ER/LESSEE:
CONTRACTOR:
Name T-MOBILE
Name:STEVE NICHOLS
Address:1300 CONCORD TERRACE, SUITE 200
Company: ERICSSON INC
City: SUNRISE State:
Address:6300 LEGACY DRIVE
Zip Code: 33323 Fax:
1 „ w4aow
City �*�*�*� Plano State: TX
Phone No.
Zip Code: 75024 Fax:
E-Mail:JOSE.DELGADO@T-MOBILE.COM
Phone No352 446 1241
Fill in fee simple Title Holder on next page (if different
E-Mail STEVE.NICHOLS(cDERICSSON.COM
State or County License CGC1 518237
from the Owner listed above)
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.
DocuSign Envelope ID: 3D700442-Al2C-419B-BCAE-0B7D1568DF4C
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
Name: APX ENGINEERING
Address: 14471 MIRAMAR PARKWAY, SUITE 202
City: MIRAMAR
Zip: 33027
P h o n e 954 744-1538
Fa
E SIMPLE TITLE HOLDER:
me: Mary Jane Spain (TR)
Ad d ress: Po Box 1149
City: HOBE SOUND
Zip: 33475 Phone:_
State
Not Applicable
MORTGAGE COMPANY:
Name:
Address:
City:
Zip: Phone:
BONDING COMPANY:
Name:
Address.
City:
Zip: Phone:
Not Applicable
State:
Not Applicable
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 recordine vour Nnfice of Cnmmpnramanr
Signature of Owner/ Lessee/Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF
a r 0 U) a rf-)-
Sworn to (or affirmed) and subscribed before me of
V Physical Presence or Online Notarization
this _11 day of I`V\Cj i , 2020 by
Name of persok making statement.
Personally Known OR Produced Identification
Type of Identification
Produced
(Signature otiotary Public- State of Florida )
Commission
REVIEWS
UAlt
RECEIVED
DATE
COMPLETED
(fin E Thwrws
Notary Public
Signature of Contractor/License Holder
STATE OF FLORIDA
COUNTY OF Seminole
Sworn to (or affirmed) and subscribed before me of
Physical Presence or X Online Notarization
this 50Sc1U#)of202%laj 16:40:32 4EWI) by
Steve Nichols
Name of person making statement.
Personally Known X OR Produced Identification
Type of Identification
Produced
r D=Ukilaned by:
(5fg Wi#� if4N6fary Public -
Commission No. GG 35039,
0TVM)DAVID WONG
Notary PJi bli State of Florid
COmn'i3# GG 350394
Commission Expires 711 /202
ANGRO
COUONTER REVIEWED �OR I REV EW INS �V EV EWEGETATION S EV EWATURTLE MREV EWVE