HomeMy WebLinkAboutBuilding Permit All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
F1E
0
County
Building Permit Application St•lu Permittingm0`9
Planning and Development Services /
Building and Code Regulation Division Commercial Residential f
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 CBDG Funding
PERMIT APPLICATION FOR:
Address: ��`o� PI'(1C "IV es N\A go-'-
Property Tax ID # - _ _ Lot No.
Site Plan Name: Block No.
Project Name: -
D DESCRIPTl0,1,. E- RK:
New Electrical Meter Second Electrical Meter (Affidavit required)
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:c� 1 Sq. Ft. of First Floor:
Cost of Construction: $ -16 QL . Utilities: —Sewer _Septic Building Height:
4O �L SEE:
Name Ptine La\ce5 pre5ef'Ue IROAS Name: Qe-n"15 r GokY"
Address: r1LA12 P, ne (,akes 4\VA Company: 0 1(3i-o -.T\100 VeC `
City: f fr-* 5W, --k State: F L Address: Jq0\ G'►E'eeY\ ID'1oG C
Zip Code: 34 Q52 Fax: City: P--6 f--Vck V\0 State:
Phone No. E- Zip Code: 33o G 4 Fax: j
Mail: Phone No Ci 5 W 'Lk2-oZ S`5
Fill in fee simple Title Holder on next page (if different E-Mail Stlr,oy\e.v\'a Si wr+S 0 �-
from the Owner listed above) State or County License GFC 1H2930C I
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.
` MENTAL� U`;
1,7711T MUTT
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 conflicts with any applicable Homeowners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Homeowners 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.
Signature of Contractor-or-Owner Builder as applicable
STATE OF FLORIDA
COUNTY OF
Sworn to(or affirmed)and subscribed before me of Physical Presence or Online Notarization
this day of 20_by
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification Produced
(Signature of Notary Public-State of Florida)
Commission No. (Seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev 10/12/21
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
I ENGINEER: Not Applicable DESIGNER/ENGINEER:G
/ pp 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 conflicts with any applicable Homeowners Assoclation rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Homeowners 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.
SYMONENA NICOLE SIMMS
, G --Notary Public-State of Florida
Signature of Contractor-or-Owner Builder as applicable ®•= Commission # HH 220898
My Commission Expires
STATE OF FLORIDA January 25, 2026
COUNTY OF (-) ro UJA R
Sworn to(or affirmed)an subscribed before me of /Physical Presence or Online Notarization
`this % day of �rt , 20 z 2-by
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification Produced
(Signature of Notary Public-State of Florida)
Commission No. (Seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev 10112121
SAVE THIS INVOICE FOR YOUR GUARANTEE DATE OF SERVICE LOCATION
Rom_ SEE BINDING TERMS ON REVERSE M —o2 ail FT. LAUDERDALE
HOOTER Roto-Rooter Services Company
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Remit to:5672 Collections Center Drive,Chicago IL 60693 0056 -t/-J/ — r
PLUMBING& k For Service Please Call 1-800-GET-ROTO(438-7686) SERVICE TECHNICIAN'S NAME I�—�—i0k.
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WATER CLEANUP (aet;aetai (854) CRC 61 *FAX(954)418-6971 • 81- O 1
1 -800-GET-Hors
SEWER&DRAIN ❑ PLUMBING. PUMPING❑
INDUSTRIAL❑ EXCAVATION ❑ DRAIN TILE❑
CUSTOMER NAME CUSTOMER NO. CUSTOMER CLASS
//'✓j L-P S / Q ❑ RESIDENTIAL 10 COMMERCIAL
BILLING ADDRESS APT. UMBER FEDERAL I.D.#
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CITY C I STATE PROVINCE ZIP/POST CUB O ER PHONE NO. P.O.NUMBER AUTHORIZATION
SERVICE ADDRESS(IF DIFFERENT THAN BILLING ADDRESS) CITY STATE/PROVINCE ZIP/POSTA
WORK ORDER AUTHORIZATION I authorize the services indicated and agree to pay the amounts specified. I have read and agree to the terms on the reverse side,
including the limits on Roto-Rooter's responsibility specified in those terms.I acknowledge that under paragraph 2(b)of those terms,if Roto-Rooter equipment gets
stuck in a pipe,I may be responsible for the cost of removing that equipment,including any required excavation.
(SIGNATURE) �� (PRINT NAME)-'--, A a
REPAIR CODE ESTIMATE AND DESCRIPTION OF WORK TO BE PERFORMED(The approximate starting date is and the approximate completion date
is .Neither date is guaranteed.Unexpected conditions or problems could cause delays.A definite completion date is not of the essence.)
�l�Pcl �4l E ,C -_ /i(_ Co r I'Z /-n/ 2 r $AMOUNT
L I Q rz�:1r. C,,d rdA, 01— a L I U q / c .v J e /
Llo,cr mkt . jca f clot'✓' 0,
ADJUSTMENTS/CHANGES IN WORK TO BE PERFORMED(Use additional invoice if eeded to describe changes)
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C(�«w�, �-o LAX (. �
RESIDENTIAL GUARANTEE COMME CIAL GUARANTEE PAYMENT
LABOR LABOR C
❑ ranch Lines months ❑Main/Branch Lines 30 days ❑ CASH ❑ CHECK NO. LABOR$— f& t �y
❑Toilet Aug 7 days ❑Toilet Auger 24 hours ❑ LABOR TAX$CREDIT CARD � NET 10 DAYS
❑Plumbin epair 6 months Plumbing Repair 90 days clC/
OVER 30 DAYS = LATE CHARGE OF 1 112% PER MONTH PARTS$ / Jy r ��
❑Pi ing Replacement ear Plumbing Replacement 90 days In the event check is returned,the CUSTOMER is responsible
Extended Guarantee 1 yea for all related bank fees. DISCOUNT$ O oy
REASON FOR NO GUARANTEE PRODUCTS$ 0
COMPLETION I acknowledge completion of the above described work which has been done to my complete satisfaction. OTHER$
---- - -- _lam• O
(SIGNATURE)'
/ TAX$
TOTAL$
(PRINT NAME)
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SUGGESTIONS FOR REPAIR/REPLACEMENT C
ITEM LOCATION ESTIMATED YOU SAVE
COST TODAY
WATER HEATER Rely on the experts at Roto-Rooter for complete plumbing
DISPOSER and drain services. Call 1-800-GET-ROTO(438-7686).
SINK Visit us at rotorooter.com for coupons, helpful hints
TOILET and more. Complete our customer survey at:
BATHTUB rotorooter.com/contact-us/customer-survey.
SHOWER And, follow us online for news, timely updates, and other
FAUCET plumbing and drain information.
DRAIN
twitter.com/rotorooter j facebook.com/rotorooter
OTHER
rotorooter.com/blog You youtube.com/rotorootertv
(Service echnician'sSignature)
INV-BR-TC1-3(10/19)L
..rint Service Technician's Name and Number) n•-=•� •^�-- -- /�
Roto-Rooter Services Company N .
Terms and Conditions
The following terms apply to all work performed by Roto-Rooter Services Company or its affiliate, the custom, indicat"u i)
the front of this form("you").
1. Your Responsibilities.You agree to(a)remove any hazards,obstructions or dangerous conditions around the job Bite not caused by
our work,(b)limit access to the job site so that people not working on our job are not exposed to dangerous conditions relating to our job,(c)
place appropriate warnings to warn of dangerous conditions when we are not on the job site,and(d)provide us with adequate access.
2. Exceptions to Our Responsibilities.WE ARE NOT RESPONSIBLE FOR(a)personal injury,property damage or other damage
or loss to you or others arising out of our work,except to the extent caused by our negligence or failure to'perform the work in accordance with
the contract between us;(b)DEFECTIVE,DAMAGED,OR DETERIORATED LINES,MOLD,LEAD PIPING,OR OTHER UNEXPECTED
OR UNDISCLOSED CONDITIONS,AND THE CONSEQUENCES OF SUCH CONDITIONS,INCLUDING DELAYS,BROKEN
FIXTURES OR LINES,AND LODGED EQUIPMENT(if we encounter such a condition,we may stop work,and you will pay us a reasonable
charge for the work performed);(c)the time required to complete our work with reasonable diligence; (d)unless explicitly stated in writing,any
damage necessary to complete our work,including damage to landscaping,walls,painting,tile or concrete or similar items;(e)damage caused
by the removal of any clean out,drain cover or cap;or(f)tasks we perform in accordance with your specific instructions.
3.Release and Hold Harmless.You release us from(and if you are a commercial customer,you will defend and indemnify us and hold
us harmless against)all damages,claims,demands,settlements,judgments,liabilities,costs and expenses,including reasonable attorneys' fees,
allegedly arising out of(a)breach of your responsibilities under paragraph 1,or(b)matters for which we disclaim responsibility under
paragraph 2.
4. Our Guarantee.If we provide a parts or equipment guarantee,as your exclusive remedy,we will give you the benefit we receive,if
any,under the manufacturer's warranty.If we provide a service guarantee,it covers only drainage failure in the line serviced,and defective
plumbing workmanship,during the guarantee term.As your exclusive remedy under our service guarantee,we will,at our option,either do the
work again at no labor cost or refund your payment.Guarantees do not apply to problems arising out of main sewer line backup or improper,
abnormal or unanticipated use or conditions.Except as explicitly stated in writing,we are not giving any guarantees or making any warranties.
TO THE EXTENT PERMITTED BY LAW,WE DISCLAIM ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS
FOR A PARTICULAR PURPOSE.You may transfer a guarantee of plumbing repair or replacement to a person who purchases the property,
but you may not transfer a drain cleaningor toilet auger guarantee.Your transferee must resent the warrant claim to Roto-Rooter at the time
Y Y g g P Y
we perform our work.We do not guarantee that our site inspection will identify all existing or potential problems.Any damages or necessary
repairs arising from plumbing problems,either ident
ified or unidentified,are the sole responsibility of the customer.
5. Limitation of Damages.Our liability to you for any claim arising out of our work on any job(other than a claim permitted by these
terms for personal or bodily injury)will in no event exceed three times the amount you actually pay us for the work on that job.EXCEPT FOR A
CLAIM PERMITTED BY THESE TERMS FOR PERSONAL OR BODILY INJURY OR PROPERTY DAMAGE,YOU WAIVE ANY RIGHT
TO RECOVER INCIDENTAL DAMAGES,CONSEQUENTIAL DAMAGES,OR DELAY DAMAGES.
6. Payment Terms.When you provide a check as payment,you authorize us either to use information from your check to make a` _
one-time electronic fund transfer from your account or to process the payment as a check transaction.In the event check is returned,you are
responsible for all related bank fees.If you fail to pay us any amount when due,we will charge you interest on the amount due at the rate of
1.5%per month(but not exceeding the highest rate legally permissible).You will reimburse us for the reasonable attorneys'fees we incur in
-all stages of collection.
7. General.These terms are part of our contractual agreement and will prevail over any inconsistent terms in any other agreement
between us,including the terms of any purchase order,and may be modified only in a written instrument signed by both of us which specifically
refers to the provisions to be modified.If any of these terms is held invalid or unenforceable,the remaining provisions will not be affected and
will continue to apply.
8. Nondiscrimination. We will abide by the requirements of 41 CFR SS 60-1.4(a)and 60-7415(a).These regulations prohibit
discrimination against qualified individuals with disabilities,and prohibit discrimination against all individuals based on their race,color,
religion,sex or national origin.Moreover,these regulations require that we take affirmative action to employ and advance in
employment individuals without regard to race,color,religion,sex,national origin or disability.
HOW TO RESOLVE A PROBLEM
•Contact the manager at your Roto-Rooter office. Everything will be done to resolve your
problem at the local level.
• If your problem cannot be resolved locally,please contact Pat Swanson,Customer Service
Coordinator,in our national headquarters:
Roto-Rooter Services Company or email pswanson@rrsc.com
Suite 2500
255 East Fifth Street
Cincinnati,OH 45202 I