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Home My WebLink About0512-0637 APPLICATION FOR PRIVATE PROVIDER FOR PLAN REVIEW-INSPECTIONSr" ST LUCIk WUNTY SCANNED Ldy aLucie Count 2300 Virginia Avenue Ft Pierce, FL 34982 CODE COMPLIANCE DIVISION Office (772) 462-1553 Fax (772) 462-6454 Application for Private Provider for Plans Review / Inspections (A/E Agreement. Revised July 1, 2003) /l St Lucie County Code Compliance Division PERMIT #: to 9-117 DATE: -hpC_.. za 2oo(o STREET ADDRESS: `635 1 J • US Parcel #: TO: St. Lucie County Building Department I have elected to utilize lerrQM. &65- 3 (Name of to Registered Architect / Engineer) (State Registration Number) (As recog zed inch ter 468, 471, Florida Statutes) s FIRM NAME: �- l Q/ / / Ll ADDRESS: / U i DU TELEPHONE #: 9-0 FAX #: (��,Z 1 _ Z. 5 — IOW as a private provider as authorized in s. 553.791, Florida Statutes. I have elected to use this "Private Provider" for: (check all that apply): V alPLANS REVIEW: VBuilding, electrical, Mechanical, Plumbing. (Affidavit Required) / INSPECTION(s): __ILBuilding, V Electrical, Mechanical, V Plumbing. FEE SIMPLE OWNER: I have elected to use one or more private providers to provide building codes plan review and/or inspections services on the building that Is the subject of the enclosedpermit application, as authorized by Part XII, chapter 468, Florida Statutes & s. 553.791, Florida Statutes. I understand that the local building official may not review the plans submitted or perform the required building inspections to determine compliance with the applicable codes, except to the extent specified in said law. Instead, plans review and/or required building inspections shall be performed by licensed or certified personnel identified in the application. The law requires minimum insurance requirements for such personnel, but I understand that I may require more insurance to protect my interests. By executing this form, I acknowledge that I have made inquiry regarding the competence of the licensed or certified personnel and the level of their insurance and am satisfied that my interests are adequately protected. I agree to indemnify, defend and hold harmless the local government and local building official(s) from any and all claims arising from my use of these licensed or certified personnel to perform building code inspection services and/or plans review. With respect to the building that is the subject of the enclosed permit application, I understand that if I elect to make any changes to the listed private providers or the services to be provided by those private providers, the fee simple owner I shall, within twenty-four (24) hours after any changes, update the notice to reflect such changes. .* 'Fl♦ E SI1VMPI..E.OWNER: (PRINT NAME OF-FEI MIPLE OWNER) (SIGNATURE OF FEE SIMPLE OWNER) ;(DATE) �� w:;- : (PHONE #:) (ADDRESS).. • `- .} NOTARY: STATE OF -COUNTY-OF---- The - -- --- -- -- - - -- - The foregoing instrument was acknowledged before me this day of , 200_ By My commission expires: Personally Known Produced ID Type of identification: Signature of Notary Public — State of AFFIDAVIT FOR PLAN REVIEW: I affirm that I am qualified under chapter 468 or 471, Florida Statutes to provide building code plan review services as authorized by s. 553.791, Florida Statutes pursuant to section 104.3.2 Florida Building Code with respect to the building that is the subject of the enclosed permit application. I understand that the local building official may not review the plans submitted or perform the required building inspections to determine compliance with the applicable codes, except to the extent specified in said law. OVER REV. 12/6/05 DMG I have reviewed the construction plans / doc xnents to determine compliance with the applicable codes. I have determined that the plans reviewed comply with the applicable codes. I accept full responsibility for compliance with all provisions of the standard / technical codes and other pertinent laws or ordinances. I provide my seal arid' signature as affidavit under oath, that the following is true and correct to the best of my knowledge and belief: - (a) The plans / documents were revie�ed by me. I am duly authorized to perform plan review pursuant to the code and hold the appropriate licenses or certificates. (b) I am qualified as a plan examiner under Part XII of Chapter 468, Florida Statutes. (c) The plans comply with the applica le codes, standards, statutes and local ordinances or regulatory agency requirements. (d) The plans comply to the laws as to egress, Life Safety Codes, type of construction and general arrangement and show the structural design. (e) The plans and design conform to the requirements of the technical codes as to strength, stresses, strain and stability. (f To the best of my knowledge, the plans and specifications comply with,the applicable minimum building codes and the applicable fire-safet� standards as determined by the local authority in accordance with the Florida Building Code and chaptel 633 Florida Statutes. (PRINTED NAME OF PLANS EXAMINER) (SIGNATURE OF PLANS EXAMINER) STATE LICENSE # Inspections: I affirm that I am qualified under s. 468 Florida Statutes to provide building inspection services as authorized by s. 553.791, Florida Statutes pursuant to,section.:l04.3.2. Florida Building. Code. It is understood that the undersigned hereby accepts the responsibility for performing all of.the required inspections identified in this document. I understand that inspections are required as (detailed' -in Section.l05 of the Florida.Building Code, the permit card, and as prescribed by the local authority having jurisdiction. I further agree to hold St Lucie County harmless for such inspections,'and accept responsibility` for compliance with all other requirements contained within. Upon completion of the structure; I will provide the Building Official a certification that the structure, electrical, gas, mechanical and plumbing systems have been erected in aordance with requirements of the technical codes. The undersigned certifies that all work inspected (and approved) will conform to all applicable codes and standards; as well as all related permit documents: In the event of any. conflict between,codes and documents, the more restrictive shall apply. A log shall be maintained of all inspections made including the date of the inspection, the inspection performed using the permit "hard card" terminology and the designation of either approved or disapproved and an inspection report shall be forwarded to the Building Department within 72-hours of making the inspection. Each inspection report shall bear the seal of the Architect / Engineer performing the inspection, along with his / her signature and the date. The permit will expire unless work is commenced (and receives an approved inspection "colored red on the permit hard card, red print indicates a required inspection which satisfies the 180-day requirement") within 180-days (60-days for demolition permits) from the issue date of the permit. All subsequent inspections shall be made within 180-day 'me frame prior to permit expiration. NO INSPECTIONS BE BE p D SVBSEOUENT TO PE MIT EXPIRAJION: AN2 NO INSPECTIONS WILL HANDLED "AFTER -THE -FACT". (PRINTED NAME OF INSPECTOR) (SIGNATURE OF INSPECTOR) STATE LICENSE # STATE LICENSE # STATE L SE / STATE LICENSE # ♦ Principle Architect / Engineer: Jerry M. Weintraub (PRINTED NAME OF Architect / Engineer) A E OF Architect / Engineer) 321-403-7062 DATE (PHONE #:) 150 Highway AlA, 004, Satellite Beach, FL 32937� � ``6, (ADDRESS) Architect / Engineer a NOTARY: Seal: STATE OF 6` COUNTY OF The foregoing instrume t was a knowle ged before me this Mday of _ By _ My commission expires: ETH VILLAFANE Personally K own Produced IDS_ T of i tl C t10 :'+'o ®`!'° IC - STATE OF FLORIDA Signature of Notary Public — State of GQMMISSION # DD450236 Whenever the owner / contractor desires ian inspection to be performed anyone of X16 the abmPo�i �t�L ��o� RYI County Inspector, a new application form must be submitted and approved by the St Lucie Couni}9�QdTiyf bbWffi-& or Building Code Supervisor BEFORE a subject inspection (s) is (are) PERFORMED. The St Lucie County Building Departm nt may at any / all times visit the construction site to ensure compliance and / or for the purpose of spot inspectio to verifying construction activities are In compliance with the construction documents / drawings. Failure to follow standard operating procedures for inspections for St Lucie County may negate any further approvals for you or your firm to perform this type of inspection. In addition, Incomplete or inaccurate inspection reports may result in failed inspections, work stoppage and / or permit expiration. All violators will be referred to the FL. D.B.P.R. Should you have any questions regarding this procedure, please contact the St Lucie County Building Department