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Home My WebLink AboutAPPLICATION FOR PRIVATE PROVIDER2300 Virginia Avenue Ft fierce, FL 34992 Offlco (?72) 462-1553 l:tlx (772) 462-1149 n MOT for ?ROD, Application forrrnTuv (AJE ement,RevisedIulyL'o0l. SGANNED ( Air BY Se Lucie County Code Compliance '� 7tv i.� +" ' Lucie Countv DATE: PERMIT #: -�-�i� t STREET ADDRESS: �� / , Parcel #:- � TO: St. Lucie County 1 have elected to utilize PiRlt4 NAME: Ivt e ADDRESS: v v P� 475)-0 I � l0(p � ;tale ItcgiAtra on Nnmbcr) FAX # SW-J- �loO_—'' TELEPHONE t'. rivate provider as authorized in s. 553.791, Florida Statutes. I h:+vc e ri sd to List,List,this "Private Providee" for: as zip (check all that apply): Plumbing Building, Electrical, i:chznical,,� iP6al�fS II<EVJ[E�'V: - . ,�//(AnidavitRequired) Building, F•lcruical, '�I :chanical, , plumbing. IldSP1GC d IOlv1(s}: rE� gy.ltgpQdE ®�Vh]IEAB: uxlr tan review andlor inspections services 1 have elected to rise one or more private providers to provide ilodnn p i rlv r ized by part X11, chapter 468, Florida on the building that is the subject of the enclosed permit appthe cal uil exec t to Statutes & s. 553.791, Florida Statutes. I understanecfionsato det ormin uI 'trpl 4e WiIII t e applicable codes, p submitted or peeform the required building P utred l uda t ., inspections shall be performed by the extent specified in said law. Instead, plans review and/or req executing this form, I licensed or certified personnel identified in the application. The law : cuuii :•s ninimwn insurance requirements or such personnel, but I understand that 1 marequiree cOrmpetencecof t be lici r:-ed or cettif ed personnel nd the level acknowledge that I have made inq 'ryregarding of their insurance and am satisfied that my interests are adequately pn'i''c+; t I agree to indemnify; defend and hold harmless the local govertmen arld i r: tl building ofcial(s) from services any and all claims arising from my use ofthese licensed or that is theed rsonnel subjecttutFtle1: t . lose tip gtni application,tI understand andlor plans review. With respect to the buildingidec that if I elect to make any changes to the listed private €ours ers hou� or the tiCt" •:-s tC be provupdateyhe not oe Eothose trefiect providers, the fee sttnple.oweter I shall, within twenty- ( ) such changes. ] I o FEB SJMPLF- VY1V1E]R: 60 �+ /��t bn�nGG �f1�_V1 ---- hwcy � d1V ATPrIlY•i!:SI P Gt)vMER) -. (prRN-rf7AMEOF FE s+ rLe Q I(DAT •) i TIQc�-`�.0 UI (ADDRESS) - NOTARY' STATE OP' COUNTY OF The fr�cgoing ins eat as acknowledged before me this .J n> Ilf sy go ��QQ mycommisvn;n1cxr Persona 1y Known Produced ID Type of idew 1 I -3110 Signature of Notary Public — State of�a AFFIDAVIT FOR PLAN R F ? [ESN: JOLENE K. SOUTHWICK i') My COMMISSION #FF079740 �.�' EXPIRES December 29.2017 (407) 398.01 s Florleallotarysewim.w, yl 20 I affirm that am qualified under chapter 468 or 471, Florida Statutes m :•i--vide builtlitlg cede plan review services as authorized by s• 553.791, Florida Statutes pursuant to section 104.1 7 1' 1 rida Building Code with respect to the building that is the subject of the enclosed permit application_ I uridrr.< a ; hat 111c focal building ofFcial may not review the plans submitted orperform the requiredbuilding inspeci:uris ' t letermine compliance with the applicable codes, except to the extent specified in said law. a VER I have reviewed the construction plans / documents to determine cdmphooce ••r h the applicable codes, i have determined that the plans reviewed comply with the applicable codes. I act q) ' Il rmpammbility Fos eontpliance, with all provisions of the standard / techuical codes and. othee'pertinent 1;rms : i rdinancus. I provide my seal and signature as affidavit under oath, that the following is true- and correct t:1 G)e ::: • of sly knowledge and belief: (a) The plans / documents were reviewed by myself. ➢ am duly aut.hr,i i>a :' 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 XH of Chapteh 4Ex, Flo- i a Statutes. (c) The plans comply with the applicable codes, standards, statute:, and I I: if ord'uteu)ces or regulatory agency requirements, (d) The plans comply to tte laws as to egress, Life Safety Codes, I+;:r n: t msnvction and general arrangement and show the structural design. (a) The plans and design conform to the requirements of the technir:i1 ct•e : s as to strongth, stresses, strain, and stability. (f) To the best ofmy knowledge, the plans and specifications cotrl)h• "r , the applicable minimum building codes and the applicable fire -safety standards m determined b;. ilia f •t t I authority in accordance with the Florida Building Code and chapter 633 Florida Statutes. IInspe dnonst I affirm that I am qualified under s. 468 Florida Statutes to provide builrLop,, ) r i ection sorvices as authorized by s. 553.791, Florida Statutes pursuantto section 104.3.2 Florida Building•, Cts& I is uitd,:rstood that the undersigned hereby accepts the responsibility for performing all of the required inspc1:l101L:• entilied in this document. I understand that inspections are required as detailed in Section 105 of the I• lei;1• Building Code, the permit card, and as prescribed by the local authority having jurisdiction. I further agree t,:1:,:h1 -I Lucie: County harmless for such inspections, and accept responsibility for compliance with all other regt rr)n,:-'• contained within. Upon completion of the structure, I will provide the Building Official a certification thatt•,c :,u:.c. Ire, electrical, gas, mechanical and plumbing systems have been erected in accordance with requirements o' flic I, t: nictd codcs- The undersigned certifies that all work inspected (and approved) will co;dbrlr 1. all applicable codes and standards; as well as all related permit documents. In the event of any conflict betw\:c,i :•-11 )s and documents, the more restrictive shall apply. A log shall be maintained of all inspections made• ineh I 1 I g the date of the inspection, the inspection performed using the permit "hard card" terminology and the ,.Ic tp, a• on of either approved or disapproved and an inspection report shall be forwarded to the Building I )epu, -,ent wittdn 72-hours of making the inspection. Each inspection report shall bear the seal of the Architect / T n:::n_'•I terforming the inspection, along with his / her signature and the date. The permit will expire unless work •XV1, enced (and receives an approved inspection "colored red on the permit hard card, red print indicates a rec -u r. pectiou which satisfies the i 80-day requirement") within I80-days (60-days for demolition permits) from thr �slI...: ate oribe permit. All subsequent inspections shall be made within 180-day time frame prior to permit expl-,tio". '40 INSUCTIONS!'S1i L B1F, PBR&Ol@1tg1E9D SUIBSBOUF-Rl1 TO PERMIT V F%PIIIRAT➢O1N: AIoII] NO i ;.P_&4:11ONS WILL RE IIAINiDL,N D "AFT E&TH E-FACT". \ / �✓iAt lCV Irteet /nnon RnVTED H�MOFArchitect/Engineer) 7 (io (DATE) Arehlter• + 1tn2: leer ��PA �I /yjn Seal: �`'' CHRISTINE L JACKMAN STATE OF �(.l�"a �/ —�7 I ti ''= MY COMMISSION q FF962316 COUNTY OF �V Ctl � EXPIRES February 18. 2020 The foregoing instru ant s a knowledged before me this day o m rn mnnoa sm t — ByIT C�/1(it° �� My commission r.<-„rro-: . 1 Personally Known V Produced ID Type of identifi adun: Signature of Notary Public — State ofi: - A lienever the owner / contractor desires an inspection to be performed'v, an-;••) a other than the above or a St Lucie County Inspector, a new application form must be submitted and approt..d tr;.• : I s St l.ucic County Building Official or Building Code Supervisor BEFORE the subject inspection (s) is (are . 1'lilt °•: 'RMfa) CM] The St Lucie County Building Department may at any / all times visit ear coin -action s)tr 10 ensure compliance • The St Lucie County Building II=- ,: taint may at any /all times visit t v coo � •.r,. '- ; sut• I ensure compliance 121 and / or for the purpose of spot i , tions to verifying construction act n,cx , ,. ,•inpliance with the construction documents / drawings. ]Failure to follow standaed operating procedures for inspections for tii Lug w County may negate any further approvals for you or your form to perform this type of inspection. Yn ,tddit i-• n, Incomplete or inaccnvate Inspection reporis may result In Tailed Inspections, work stoppage wO ! ,I, -ermil eNpiration. All violators will be referred to tine &. TD&2.ld. Should you have any questions regarding this procedure, please contact ins- S• ' cic C'-onoty Building Deportment 6 Building ®Tfleiall or Building Code Supervisor Print Name �igtraturc — -- )mate