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Home My WebLink AboutAPPLICATION FOR PRIVATE PROVIDERST ILiU(C1I]E 0C 1",N`TY CODE(��[YI11�it �r'��I(C�, I[)�.V][S ON 2300 Virginia Avenue Ft Fierce, FL 34932 QFiico (772) 462-1553 I.ax (772) 462-1145 Application for P)rllvate Provider for PRORS R, -) iewr (AM Agreement, Revised July 1. ; OI . St Lucie County Code Compliance )tvisr, SCANNED BY St. Lucie Count,/ 1 Qttts��iiomis PERFIIT #: DATE: _. 5 STREET ADDRESS: 5a 55 (i� �� 1 f'—t t'e�qq 1 Parcel Ik TO: St. Lucie County Building1D,.epartment /I Ihave elected toutilize nat[Y1QrI A f up-,i PE - _•- VlY (Name of. Stnto Registered Arch tecl I Eltginecr) . <tate ltcgixtmlion Nembu) ,M t game in chapter d68, f7t, Plorido Stetuta) FiRM NAME: V_� t ` (J _ n Q�_.. ADDRESS: h IP I�EYi rlJ-each d'L �-11 a l �' I Tr,LEPHONE #: FAX # �7 as a private provider as authorized in S. 553.791, Florida Statutes, l h:mclrri sd to use this "Private Provider" for: (check all that apply): 2114 NS I-EVIE9W; Building, Electrical,ldavil Required) SFIIECiI®Id(s); ,Building Electrical, I:chanictl, - Plumbing. FEES SIMMY OWNER.' ER.' i have elected to use one or more private providers to provide buildin le utd r. tlan revietiv and/or inspections services on the building that is the subject of the enclosed permit application, .t. tiuriv r ized by Part X11, chapter 468, Florida Statutes & s. 553.79 1, Florida Statutes.Iunderstandthat -the local building.. t:Icial may not review the plans submitted or perform the required building inspections to determine tarp i:a -�c with the applicable codes, except to the extent specified in said law, Instead, plans review and/or required Null i ., inspections shall be performed by licensed or certified personnel identified intheapplication. The law:cuuii:•c ninitnutninsurance: requirements for such personnel, but I understand that 1 may require more insurance to ;n etec' my interests. By executing this form, I acknowledge that I have made inquiry regarding the competence of! be lice r:.cd or certiried personnel and the level of their insurance and am satisfied that my interests are adequately pran:C.'.: r I agree to indemnify, defend and hold harmless the local governmen and i t•: tl building ufficial(s) from any and all claims arising from my use of these licensed or certified personnel nt imdi r• buiGia•,g code inspection services and/or plans review. With respect to the building that is the subject of ute : t iosad permit application, i understands that if I elect to make any changes to the listed private providers or the 4 r•• •: s t ku"Et providers, the fee simple.owner 1 shall, withtn''nventy-four (Z4) homes atlr : ny h nett t t such changes. � • UM -01 (SIGNATUa!• Oii ! E�SIMPLE lVlEJER) IT2 tMl (2) NOTARY: STATE OR F�or1c1A' lA c:a C®Yll�lTV O Wn i Y eK The Progoingy� lrument was acknowledged before me this L 3 ? of 20 F3Y SQh� K�S/ Mycommissinnc::r Personally Known v Produced ID of idmitic" o SignaeureofNotary public -- State of�: A.7F>N']iIIDAVIT FOR ILAF IR EV a 9W: I affirm that I am qualified under chapter 468 or 471, Florida Stamc.N t11 :•o -vide building code plan review services as authorized by s. 553,791, Florida Statutes pursuant to section 10•I. , 2 t -rida Building Code with respect to the builduig that is the subject of the enclosed permit application. I umiri sty: r; hat the local building official may not review the plans submitted or perform the required building inspecimris , 1 etermirie compliance with the applicable codes, except to the extent specified in said law, 0 VER JULIE A BARRETr �� a, MY COMMISSION #FF132752 ''w.� ad'.• EXPIRES September 28, 2018 (407) 398-0153 FloridallotarySemim.mm • I have reviewed the constructir, ns / documents to determine compliance ••r I'applicable codes, i have determined that the plans revie :- -amply with the applicable codes. accep ' t responsibiiity for compliance with all provisions of the standard / technical codes and other'pertinent L:,v, :; , rdineneus. I provide my st d eaan signature as affidavit under oath, that the following is tpite• and correct t:i t:ie :::. of nay knowledge and belief: (a) The plans / documents were reviewed by myself. ➢ am duly ai r.11r+i irr .' o 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 48:r, pin i ,r Statutes. (c) The plans comply with the applicable codes, standards, statute:, and I 1 : it oldhnalccs or regulatory agency requirements. (d) The plans comply to the laws as to egress, Life Safety Codes, t ,:m of.a nivuction and general arrangement and show the structural design. (e) The plans and design conform to the requirements of the technic;ii ee•C : ; as to strength, stresses, strait and stability. (f) To the best of my knowledge, the plans and specifications cowl it i the applicable minimum building codes and the applicable fire -safety standards as determined b) tlic r •a ; I authority in accordance with the Florida Building Code and chapter 633 Florida Statutes. IIrrnSlpeodnonas: I affirm that l am qualified under s. 468 Florida Statutes to provide builrl:rlp, ire ectinn services as authorized by s. 553.791, Florida Statutes pursuant to section 104.3.2 Florida Building•. ('udc l is understood that the undersigned hereby accepts the responsibility for performing all of the required inspctiiim :• : entitied in this document. I understand that inspections are required as detailed in Section 105 of thc 1• let 11. Building Code, the permit card, and as prescribed by the local authority having jurisdiction. I further agree t,. l:,:h l -I Lucin County harmless for such inspections, and accept responsibility for compliance with all other regt nniur contained within. Upon completion ofthe structure, I will provide the Building Official a certification thatri, :,a i.e. ire, electrical, gas, mechanical and plumbing systems have been erected in accordance with requirements o' Iie it t : nicel crijus. The undersigned certifies that all work inspected (and approved) will co:-forin i. all applicable codes and standards; as well as all related permit documents. In the event of any conflict betv,rcri : ,rl is and documents, tha more restrictive shall apply. A log shall be maintained of all inspections made ::tell I : g the date of the inspection, the inspection performed using the permit "hard card" terminology and the :.Ir ;[ a• on of either approved or disapproved and an inspection report shall be forwarded to the Building 1)epu: t-.ent within 72-hours of making the inspection. Each inspection report shall bear the seal of the Architect / I 0l::1)_'1 rerforming the inspection, along with his / her signature and the date. The permit will expire'unless work •:• ,:t•rr enced (and receives an approved inspection "colored red on the permit hard card, red print indicates a rect r-ct r. pection which satisfies the 180•day requirement") within I80-days (60•days for demolition permits) from tl:r : si r..: ate of-ihe permit. All subsequent inspections shall be made within 180•day time frame prior to permit expi: ❑tin:•. 10 It!-W sCTI®NS WILL BE (°Yl�rAn n lEpgtr LuP (PRl NAME OF1Archdeel/Engineer) II (D LJ)— sIGNATURE 111 A,xr: �ct 11§mgmeeri _�q-.�rI Architerr ' Eti2. leer NOTARY- seat: STATE OF COiJNTIf OF tN�r The foregoing instru en s know edged before me thisqf*y o' _ �0 By j�lyr PL (A4e lid commission Personal/ own ProducedlD T oofI en'fircautmn: Signature of Notary public— State of—iq: Whenever the owner / contractor desires an inspection to be perfotmed'r anp•) a other thin d MWWON NFF962316 County inspector, a new application form must be submitted and approt-rd b:, i r St Lucie o ildW8W@PnrarY 18.2020 or Building Code Supervisor BEFORE the subject inspection (a) is (are i'Iilt r•::1ZMfll 14°CI°ili4)'57 rm"b0nM MC<.Wart ' Cxai The St Lucie County Building Department may at any / all times visit t iv r.un ;•t -action site• to ensure compliance -o--r•-^•••e.......,y "u„ y i au ❑roes visit t•n• and octn i.aCti4tt sih• to ensure compliance construction documents for the paase of spot'= actions to verifying consttvction act • i " - ,:iinpliance with the documents/ drawi'. L 2 J iP'ailuro to follow standard operating procedures for lnspeetions for,"""' it County may negate any further !approvals for y004 or your firm to perform this type of inspection.. In a ddi,f-• n, itacolliplete or imaccurrate inspection reports MAY result in failed tnspeetions, work stoppage a:,( + it, •,ermil oNpiration. All violators will he referred to rho Pr ]� N Should you have any qucationa regarding this procedure, please contact;:..- iz- O Building (Mcial or Building Code lbmpervisor Print Name SERnaturz Cie ('C,sgry BuildingDepertment Date