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Home My WebLink AboutAPPLICATION FOR PRIVATE PROVIDERST iLU CJI1E (C�—DIT Y (CO-D , C®i�(I�R,�AN� �' 2300 Virginia Avenue Ft Fierce, rL 34992 office. (772) 462-1553 lznx (772) 462-1148 SCANNED BY St. Lucie CRun PPt�: 16ation for Private ])Dli®anaferr ff®ir FUOunS n@w (A/E Agreement. Revised July 1. 2IA)) StLueie County Code Compliance '�>tvu< r I>R"IIT 0: STREET ADDRESS: Parcel AATL': RECHVE® DEC 0 8 2015 PERMITTING I I / Z 41iS St. Lucie county, FL sass IJb� Nw� Vi119_ r--+,P,9qq TO: St. Lucie County Building Department �I 6 rn�rhael �c Pe_ q?sw s9.� a 1 have elected to utilize :tale Ite ,ititmtion Namber) (Name of. Stato Registored Archacct /5ngmecr) !' ��AA (As rccognimd in phaptcr46B 411, Flodda statutes) ORM NAME: _ /i• t ita%/LCCf / —f — ADDRESS:-'•�7'µ' f%be Vt°—��'c�j�l'G _3296� TEL.EPI-IONE •: UI ) 669 —1257 FAX 1 7-7 L) _569 ,` o q I as a private provider as authorized ins. 553.791, Florida Statutes. I h:,vc• uivri sd to usu this "Private provider" for: (check all that apply): Pl(AKSRZVXBegr; Building, Electrical, „ '' .:chanical,, _ Plumbing_ o (AltidavitRequired) l :chattical,-sPlumbing. V INSPRC'1t ION(* ;Building, Electrical, FEiE 59141'l1,lE ®WF1SR' i have elected to use one or more private providers to provide buildings torte's )lan reviehv and/or inspections services on the building That is the subject of the enclose( permit application, .:5 tinrl„ r iaed by Part X11, chapter 468, Florida Statutes & s. 553.791, Florida; Statutes. I understand that the local building t: icia] may !tot review the plans submitted or perform the required building inspections to determine onhpl:.7 cc with the applicable codes, except to the extent specified in said law. Instead, plans review and/or required !: I.ul,l t ., inspections shall be performed by licensed or certified personnel identified in the application. The law: uoi ii vs ninimutn insurance requirements for such personnel, but 1-understand that I may require more insurance to ;:, o! rc' my interests. By executing this form, I acknowledge that I have made inquiry regarding the competence of the licrr:•ed or certified personnel and the level of their insurance and am satisfied that my interests are adequately pru!rc!t v I agree to indemnify, defend and hold harmless the local governmen a i.l i ,.: it building official(s) from any and all claims arising from my use of these licensed or certified personnel to i:urft r• buiGlu•,g code inspection services and/or plans review. With respect to the building that is the subject ct'the : t . loscd permit application, i understand that if I elect to make any changes to the listed private providers or the cr • es to be provided by those private providers, the fee simple.owner I shall, within twenty-four (24) boll,'+ :kf1:' ay c hangcs update the notice to reflect such changes. o FIFS SIMPLF, O WNSIRU /tea ✓ass, Bmn M�1w� 60rnmun/ (PRINT NAME OF 1-SE SIMPLE OWNER) ivtgC / (SIONATUEI. O°!! •SIMPLE Ot Z�l 5 O72) 56•q-,g53 il�NEif,) (DATE) gas 2ofh Pl�h� ✓?x-O i3 d-' rL 3z96 -- 1M3 (ADDRESS) (ADDRESS)121 NOTARY' �Yrl�1y STATE Op Lott +° �C JULIE A BARRErr COUNTY OF 5h t df�i7�yA{y MY COMMISSION #FF732752 ZY'A The f regoina 1�Iy 60r011hISRIi711 C::C �' gn' strument was acknowledged before me thisC(7 c;•:p ui Wit Q—Iv, Off FIRES September 28, 2018 By(�i i4071798-0153 "Wservice.mm �jrj 'CS-__.. itlalloto PersonallyKnowu ProducedlD T deoiicat't1' __ Signature of Notary Public --State of AWFA DAVII'ICIFOR AN at a: V IF,'W: I affirm that I am qualified under chapter 468 or 471, Florida Statu,ca tb :n- •vlde building code plan review services as authorized by s. 553.791, Florida Statutes pursuant to section 10•I.1 z :' ,rida flu ilding Code with respect to the building that is the subject of the enclosed permit application_ I undri: lxi•; hat 1110 lot:al building official may not review the plans submitted or perform the requiredbuilding inspecutmi ' t -eterminc compliance with the applicable codes, except to the extent specified in said law. aM--R I have reviewed the constructiw .,, ,ns / documents to determine complcaru:c ' •r determined that the plans reviewed comply with the. applicable codes. I ah:ccl) ' h two applicable codes. 1 have it responvihility for compliance with all provisions of the standard/ technical codes and other'pertinent h:w.1..: I signature as affidavit under oath, that the following is true- Bud correct t-.) tno : e. rdinancos. I provide my seal and of oy knowledge and belief: (a) The plans / documents were reviewed by myself. I am duly authr,I irc•: o perform plan review pursuant to the code and hold the' appropriate licenses or certifcaies. (b) I am qualified as a plan examiner under Part XII of Chaptet 46.7, 1:1, r i .1 Statute. (a) The plans comply with the applicable codes, standards, statute, and I I: it ordinrmces or regulatory agency requiretuepts, (d) The plaus comply to the laws as to egress, Life Safety Codes, I'• -:e n:'r mstruction and general arrangement and show the structural design. (a) The plans and design conform to the requirements of the technic:iI c:•c : s as to srtt+ngth, stresses, strait and stability, (f) To the best of my knowledge, the plans and specifications cotnpiv v: I due applicable minimum building codes and the applicable firFsafcty standards as determined b} III,, i-;; I audiority in accordance with the Florida Building Code and chapter 633 Florida Statutes. Anspeehions: - I affirm that l am qualified under s. 468 Florida Statutes to provide bWE:ry, i r; action services as authorized by s. 553.791, Florida Statutes pursuant to section 104.3.2 Florida Building'. Cad.- t is understood that the undersigned hereby accepts the responsibility for performing all of the required inspccnnn:• , entilied in this document. i understand that inspections are required as detailed in Section 105 of the I- Itn i I. Building Lode, the permit card, and - as prescribed by the local authority having jurisdiction. I further agree t,:. I:,,ItI -I Luchi County harmless for such inspections, and accept responsibility for compliance with all otherregt i-rnm'+- contained within. Upon completion o£the structure, I will provide the Building Official a certification tbatt•tc %u i.•:. ire, electrical, gas, mechanical and plumbing systems have been erected in accordance with requirements of !ht: I, t : nic:tl co(Jcs- The undersigned certifies that all work inspected (and approved) will ceafurn', I. all applicable codes and standards; as well as all related permit documents. In the event of any conflict betwe. •n : • id is and documents, the more restrictive shall apply. A log shall be maintained of all inspections mach- latch 11: g the date of the inspection, the inspection performed using the permit "hard card" terminology and the .k%iP, a• on of either approved or disapproved and an inspection report shall be forwarded to the Building grpii; r tent within 72-hours of making the inspection. Bach inspection report shall bear the seal of the Architect / Inn; n_ i )erforming the inspection, along with his / her signature and the data. The permit will expire unless work > A,r•r enced (and receives an approved inspection "colored red on the permit hard card, red print indicates a reu rce I'. poctimu which satisfies the 180-day requirement+') within 180-days (60-days for demolition permits) from tl:t- :.sir..: ate nrthe permit. All subsequent inspections shall be made within 180-day time frame prior to permit expl: otiw'. '40 INSPECTIONS aF YLL 13B o Arohitect/lEngi ear- 0 t�,h 1 4. L;,e. pI-� (PRINTED NAME OF Architect/Engineer) CSIGNATU -r�+ ai:'r: vt/1°ngmcer) Il�a��rs zr257--- (DATE) (PI,I ¢III '. -2-03D 37 rti l9ve- Veco r nc,11. Archite(-t IrriZ% leer ,oM•r� JULIE A BARRETT NOTARY' SOaI. MY COMMISSION #FF132752 SfATEOF oftIJ EXPIRES September 28, 2018 COUNTYOF t a. _ Uler- TheMgohi Instrument wasacknowle ed before methi� dayoilvoJemiie_r _Ia_ FlaridailotarySemim.mm By 1 3 \ t MC%ei � , �I= Aly commission t:< Personally Known 1 Produced ID fIdentificaliu Signature of Notary Public- State of IFC-: Whenever the owner / contractor desires an inspection to be crformed''v: an.') a othor than the above or a St Lucie County Inspector, anew application form must be submitted and approt : t1 I)..• :-I.. St Lucie County Building Official or Building Code Supervisor BEiFORP the. subject inspection (s) is (are I'Iilt RtV1¢:1) • Cu] The St Lucie County Building Department may at any I all times visit t it t.om,i -action sift- to ensure compliance The St Lucie County Building Department may at any/ all times visit t.n coiT +, 't sue to ensure compliance C21 and / or for the pure®so of spot ';actions to verifying construction act +•du:; i rmplianee with the construction documeuts / drawl IFai➢Ura to follow standard Operating proeedures for inspections for Si i.u. ra County may negate any further approvals for you or your tfirm to perform this type of inspection. In teddi, i,n, Incomplete or inaccurate inspection repor➢s may result in failed inapectlons, wort( stoppage a:�o + n• '-ermil expiration. All violators will be referred to the EL. %jjjE.j Should you have any gueationa regarding this procedure, please contact I!.,. s• ' cie (=ongry Building Department 0 Building Maw or BOOMS code Supervisor Print Name $Ignatoorx — --- ImAYe