HomeMy WebLinkAboutAPPLICATION FOR BUILDING PERMIT CERTIFICATE OF CAPACITYOFFI '.USE.ONLY.
`DATEFILED: ' I
PLAN �.IEVIEW FEE: REC�IPT NO.:
URRENCY FEE: �r —S RECEIPT NO.:
PERMIT NUMBER
CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEP11M
PLANNING & DEVELOPMENT SERVICES DEPARTMENT
BUILDING & co DE REGULATIONS DIVISION
x 2300 Virginia Avenue
������D Ft. Pierce, FL 34982-5652
— - J 772-462-1553
By
ApPLICA'TI®1 ISULDING PERMIT
CERTIFICATE ®f CA-PACITY/Z®NIING COMPLUNCE
PROJECT INFORMATION
_ f LOCATION/SITE ADDRESS ---
2. PROJECT NAME: SITE PLAN
3.
PROPERTY TAX ID #: - � O�
4. LEGAL DESCRIPTION (attach extra sheets if necessary):
6. PAGE NO. 7. BLOCK NO. 8. LOT NO.
5. PLAT BOOK
10,
11
PARCEL SIZE (ACRES/SQ FT.): LOT DIMENSIONS:
PROJECT OR WORK ACTIVITY:
SETBACKS (ACTUAL) FRONT: ( CU BACK: RIGHT SIDE: 1 S LEFT SIDE: fS
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
[ ] NEW CONSTRUCTION [ j EXPANSION/ADDITION _ [ j INTERIORNTI RENOVATION
[/rRESIDENTIAL
AL
[ ] OTHER (SPECIFY)
13., DESCRIPTION OF PROPOSED USE-
14. SQ . FT OF CONSTRUCTION: 15. SF. FT 1st. FLOOR
16. VALUE OF CONSTRUCTION: $
flue of construction is used to determine the amount of permit fees to be assessed. St. Lucie County reserves the right to question and/or modify the indicated
of construction ifitis demonstrated that the submittal figures arenot consistent with similar types of construction activities. If the valueis $2500 or more, it
)RDED Notice of Commencement must be submitted with this application.
`.CIDV Form No.: 001-02
{
UPDAPED 6125/09
1
OWNER NFORMATHON
OWNER
"FO VI�A1111911
NAME:
t ATE
ADDRES STATE: ZIP:
CITY:
fl-: Email.
PHONE A(DAYTIME): OWNER LISTED ABOVE, PLEASE
IF THETEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE 0
FILL IN NAME AND ADDRESS BELOVI.
FEE SIMPLE TITLEHOLDER:
ADDRESS:
CITY: STATE: ZIP:
PHONE (DAYTIME):
comirmayoRomFoRmAirom
J,qqqq
ST. of FL REG.CERT #: ST. JWIE COUN CERT #:
TM/o Y
BUSINESS NAME:
QUALIFIERS NAME: A
ADDRESS:
A4& A
CITY: - STATE: W. - ZIP:
PHONE (DAYTI11v1E):&?b FAX NO. "-Sb�F Email:
.cam
ARCIRVENGINEER:
ADDRESS:
CITY: STATE: ZIP:
PHONE (DAYTIME): C__)
BONDING COMPANY: 'v
ADDRESS:
CITY: STATE: ZIP:
MORTGAGE LENDER: A) 11q
ADDRESS:
CITY: STATE: ZIP:
BOORTANT NOTICE: When a perndt is issued and it is not picked up within 60 days after notification
it will be voided and returned to you by mail.
M
CERTIFICATION
This I�pplication is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate of capacity,
if ap licable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit and that all
wort 'I will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
may be required for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS,
A � AIR CONDITIONERS, FENCES, ETC., not otherwise included with this building permit application.
St. eie County makes no representation that its granting of a permit will authorize the permit holder to build the subject structure
whic is in conflict with any applicable Homeowner Association rules, bylaws or any covenants that may restrict or prohibit such
strucl we. Please consult with your Homeowner's Association and review your deed for any restrictions which may apply.
The ollowing building permit applications are exempt from undergoing a full concun ency review: room additions, accessory
strue,,' es (all types), swimming pools, fences, walls, signs, screen rooms, utility substations & accessory uses to another non-
resid6ial use.
TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOBSITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
NOT CE TO APIPA�I�ANT. - -iF =I-T`ISNOT 4YOUR RIGHT; =TITLE; AND INTEREST-THATuIS SUBJECTO
ATTACHMENT: AS A CONDITION OF ISSUANCE OF THIS PERMIT, YOU PROMISE IN
GOOD FAITH TO DELIVER A COPY OF THE CONSTRUCTION LIEN LAW NOTICE TO
THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT.
O R OR CONTRACTOR SIGNATURE
I�
STA OF O
CO OF
The f regoing instrument was acknowledged before
me day of 20
by
CSC
who is!,lpersonallyknown _,/ or has produced
IANCY MIMS ARMSTRONG
Y COM04ISSION # 652
EXPIRES January 30, 2015
CONTRACTOR SIGNATURE
STATE OF O A
COUNTY O
The foregoing instrument as acknowledged before
me this � ay of 20J3,
who is personally known Zor has produced
as
NANCY MIMS ARMSTRONG
MY COMMISSION&W59652
EXPIRES January 30, 2015
NOT TWO (2) SIGNATURES ARE REQUIRED. EACH SIGNATURE MUST BE NOTARIZED. IF APPLYING FOR
THIS BUILDING PERMIT AS AN OWNER/BUILDER, THE OWNER MUST PERSONALLY APPEAR .TO SIGN
THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THIS APPLICATION.
OWNER BUILDER AFFIDAVIT WILL BE REQUIRED FOR ALL OWNER/BUILDER APPLICANTS. '
y
For eeffic in: tlructions see appropriate permit &ecklist, 4 ;
t
OFFICE IJSE ONLY
SECTION
TOWNSHIP
RANGE
MAP NO.
ZONING
V
LAND USE
L
LOT CVG %
TAZ NO.
FLOOD ZONE
FIRM MAP #
r
IS" FLR ELV
MAX HGT
CONST TYPE
OCCUP TYPE
MAX OCCUP
# OF FLRS
WATER
SEWER
SPRINKLERS
STORMWATER
LOT OF REC
LOT OF REC
LOT SPLIT
LOT SPLIT
Before 1/1990
After 1/1990
REQUIRED
APPROVED
_REPORT
" -
^AREA
----
CODE
��
FEE
FEE
(RADON)
LIBRARY
PUBLIC BLD
PUBIC BLD
PARKS
IMPACT
IMPACT FEE
IMPACT
IMPACT
FEE
CORRECTION
FEE
FEE
GENERAL
°SCHOOL
ROAD
CREDIT
Y
N
LAW ENF
IMPACT
IMPACT
IMPACT
FEE
FEE
FEE
FIRE/EMS
DRIVEWAY
Y
N
DRIVEWAY
ADMINISTRATIVE
IMPACT
REQUIRED
FEE
VARIANCE FEE
FEE
SPECIFY
MECHANIC l% ROOF
NON -CONFORMING
MISCELLANEOUS
SUBS
ELECTRIC GAS
LOT OF RECORD
FEES
REQUIRED
PLUMBING ✓
FEES
DATE SENT TO ADDRESSING- /
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEATURTLE
MANGROVE
REVIEW
CouliTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
blLA
/
RECEIVED
DATE
' 1 y
"1
Ld
COMPLETED
INITIALS
4 ► ' 1 � 4