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DateAPPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE Permit Number:
�o s
- 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: �nnp
Address: In 5 5 E Tlfff 1 C
Property Tax ID#: ?j q I bN7 J Q()0— (T Lot No.
Site Plan Name: Block No.
Project Name:
1I rip
dap - - R_Olcr i 1)&h Vbt fcoc ckrk
NLICIectrical Meter Second Electrical Meter
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: 't/�( Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —Sewer _Septic Building Height:
Name y Name:
Addre,��ff��: r1 SLR TF�QAC'�' Company:
City: rd,�'�'�1 L-cr', State:_� Address:
Zip Code: � y�J Fax: City: State:
Phone No. 7 �� Zip Code: Fax:
E-Mail:WffG 112P J0. 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.
If value of HAVC is$7,500 or more,a RECORDED Notice of Commencement is required.
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 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 be re commencing work or recording our Notice of Commencement.
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Sign ure of(YviKer1YW91Co 7
ractor as Agent for Owner Signature of Contractor/License Holder
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STATE OF FLORIDA STATE OF FLORIDA
I 14 A
COUNTY OF COUNTY OF
Sworn to(or affirmed)and subscribed before me of Sworn to(or affirmed)and subscribed before me of
Physical Prese pr�_Online Notarization Physical Presence or Online Notarization
this ay of 202f by this day of 12020 by
— UJ al '1P 4 . �;&I(
Name of person making statement. Name of person making statement.
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identifica Type of Identification
Produced t ( WProduced
(Signature of Notary Public-State of Florida ) �� u, (Signature of Notary Public-State of Florida)
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Commission No. (Seal) 3 Commission No. (Seal)
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REVIEWS FRONT ZONING �tVPLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW �j`�� REVIEW REVIEW REVIEW REVIEW
DATE O
RECEIVED N^N 70
DATE
COMPLETED
ev.
Q 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.
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.
ere.
If you sell or lease a building you have built or improved within one year after cons complete, then a
presumption is created that it was built or improved for sale or lease,which is a violation of th' exe o .
ee
You may not delegate the responsibility for supervising work to a licensed contractor who is nsed to perform
the work being done. Your construction must comply with all applicable laws, ordinances, codes, and
zoning regulations. 70now
e.
I understand that the building official and inspectors are not there to design or give ad ic to meet the
minimum code.I understand that as an owner-builder that any contract disputes with sub-contractors and I mued in a civil
court with the advice of an attorney. This department will not mitigate any contract disputes.
I�nyit�I e.
I understand that if I compensate any person or company for work performed they are required-td b 1 nsed 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
I understand that if any person that is unlicensed and uninsured gets injured on my construction e - ey 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. Initi re.
To qualify for this exemption under this subsection, an owner must personally appear, si the ding permit
application,and initial the above
I hereby acknowledge that I have read and understand the above disclosure statement and that I rther understand
that any viol tion f the terms of the owner/builder exemption shall be rep ed b e Bu ing and Zo n
Dep ent a to 'da Stat Department of Professional Regulation. and owle ed on this
day of
caner uild Sign re
STATE OF FLORIDA
COUNTY OF �'�'l,( j{-A_
The foregoing instrume was ac owledged b fore me this r(o day of 2�
by who is personally known to me,or who has
prod ced as identificatio
ark, (( on 4)It') �tPRY P��
zo St
Signs ure of Type or mt Name of tary ®� Ct�mJ)Fio,;daKota HN
Title:Notary Publi Commission Number '°;;;q My Co Ss'on # 7 sio0ublic
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