The URL can be used to link to this page

Home My WebLink AboutAPPLICATION FOR PRIVATE PROVIDER2300 Virginia Avenue Ft Pierce, FL 34992 ( -)f 1co (772) 462-1553 . (772)A&WB j) Lucie County Application for P>rav�>tiO )��®dudlerr ft®ir plain, , n�wr 1 Qrt��e ��u��s (All; Agreement. Revised July 1. =001 St Lucie County Code Compliance PERMIT ier�e 1 STPLBET ADDRESS:"i� Parcel TO: St. Lucie 1 have elected to 1 U u.4(�I VlY I 'fate l:cgi�lmtio 1mm6cr) P1Pth4 NAME: ►•�i-� t � (i-a1 �`�,'�_ I ADDRESS: 1 FAX d � TELEPHONE #: as a private provider as authorized in s. 553.791, Florida Statutes, I huge ch-c i sd to usu this "Private provider" foe: (check all that apply): Plumbing. Electrical '.i:chzrtical,,�. IPLANSP-ZVIF W: Budding,— (Attidavi[Required) `Building, Electrical, I:chanical, _ Plumbing VImsP1CCTIOlv1(s): I.-EIE s0h2my OaA N Els,: 1 have elected to use one or more private providers to provide li 'ar,r'• r r ized by part XII chaptert468, Florida ions s on the building that is the subject of the enclosed permit application,the Statutes&s.553.791,Florida Statuts.itm�sestanfidngat dethe ecal rminul'�mPl:a ldiril' 1: 4eWith the applicable codes, except submitted or perform the required building' P required l•uda t ., inspections shall be performed by the extent specified in said law, instead, plans review and/or req uirements for l licensed or certified personnel identified in the application. The law : tantit e•c niniittuta insurEly ance re executing this form, MY ir-te-'ests- e tu pi such personnel, but I understand that m t I mayequ <hrmctenmoe escof Ibc lirxr: d or certi! ed personnel and the level acknowledge that I bane made inquiry g e cop of their insurance and am satisfied that my interests are adequately pruux:; I- I agree to indemnify, defend and hold harmless the local governmen and i : d building official(s) from services any and all buiclaims arising from my use of these It a building that th t is the rsubject tc 1�111c1: i loscdlpci-m appliil'i; code cation., understand and/or plans review. With respect to the building _ that if 1 elect to make any changes to the listed private providers or the cr :s to be provided by those private providers, the fee simple.owncr [shall, within twenty-four (24) hour% air:- ny changes, update the notice to reflect 0 (AI)DRE55) _ NOTARY" STATE Op' ^ v�v - coUNTY OF The ft cgoing in me t was ackt By Person y Known Produce4 signature of Notary Public — State before me, this lit My Commission csr 'es: - Type ofidemilicul�•t' —_ -n JOLENE K. SOUTHWICK MY COMMISSION #FF079740 EXPIRES December 29, 2017 I affltin that I am qualified under chapter 468 or 471, Florida StaLW!-% M :,,,.vide building code plan review services as authorized by s. 553.791, Florida Statutes pursuaut to section 104.1 2 i -rida Building Cade with respect to the building that is the subject of the enclosed permit application_ I under sL: r: hat the local building official may not review the plans submitted or perform the required building inspect:ons 'I etermine compliance with the applicable codes, except to the extent specified in said law. OVER l I have reviewed the construction plans] documents to determine compbnni:e ••r It the applicable codes, i have determined that the plans reviewed comply with the, applicable codes. I aceep ' Il respongihility for compliance with all provisions of the standard / technical codes and other'pertiaent l;nvs r i rdinanccs. I provide my seal and signature as affidavit under oath, that the following is true- and correct t-., t;io . of -my latowledge and belief (a) The plans I documents were reviewed by myself. l am duly aur.lim ii:<: o perf )rm 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 46-R. I'll r i a StatuUsc. (c) The plans comply with the applicable codes, standards, statutes and I i : it ordiriamces or regulatory agency requirements. (d) The plans comply to the laws as to egress, Life Safety Codes, lvi:C ti: r msuuction and general arrangement and show Lite structural design. (e) The plans and design conform to tiro requirements of the techror:il c: t : i as t<i snerigth, stresses, strain and stability, (f) To the best of my knowledge, the plans and specifications corr-piv w i the applicable minimum building codes and the applicable fire -safety standards as determined b} ilic t•:; 1 authority in accordance with the Florida Building Code and chapter 633 Florida Statutes, 1[mtsp�@�nomtst I affirm that I am qualified under s. 468 Florida Statutes to provide buiLt:ng it, action sorvices as authorized by S. 553.791, Florida Statutes pursuant to section 104.3.2 Florida Building. Cutic t is undt rscood that the undersigned hereby accepts the responsibility for performing all of the required inspceilow. entitled in this document. I understand that inspections are required as detailed in Section 105 of the I• let i I. Building Code, the permit card, and as prescribed by the local authority having jurisdiction. I further agree t:. I:ttit I -i Lucio County harmless for such inspections, and accept responsibility for compliance with all other regt i ins: t• CmItrtined within. Upon completion of the structure, 1 will provide the Building Official a certification tbat tic su i.c . ire, electrical, gas, mechanical and plumbing systems have been erected inamordance with requirements o' the It t: nic:tl ceAes_ The undersigned certifies that all work inspected (and approved) will conform i. all applicable codes and standards; as well as all related permit documents. In the event of any conflict betw.:an :• t� I is and documents, the more restrictive shall apply. A log shall be maintained of all inspections made I:icb i I t g the date of the inspection, the inspection performed using the permit "hard card" terminology and the ;I< tp ;i• on of either approved or disapproved and an inspection report shall be forwarded to the Building I )clv.irt•• ,cat within 72-hours of making the inspection. Each inspection report shall bear the seal of the Architect / I nitro _••i rerfomhing the inspection, along with his / her signature and the data. The permit will expire unless work :• .a•t•r enced (,rod receives an approved inspection "colored red on the permit hard card, red print indicates a rota r<'u r. pectiou which satisfies the 180-day requirement") within Igo -days (60-days for demolition permits) from tLi• sir•.: ate orihe permit. All subsequent inspections shall be made within i80-daytime frame prior to permit expivtio".'gO1NaEl' ''I®N8aF/1lLLI31F 17EE&O1gR9E9DSlIlaSE 6IEN0 TO PERMIT XPII1RA51I®N;.4 D NO1�;••PCTIONSWILL D 111f4.ltllYr.IGrY ".rer u r.uc- u va m-r eau, a . p �e hitect/ a 'nt�i eel: t t� , - - tl(PR DNchiteci/ n ineer1 (SIGNAT E:�:�: :'r:ct/Irgmecq (DATE) (pl t t:al IOD -?R -QA),e, ?, C_&D (ADDRa,SS) Architect r Ittit : leer - -NOTAlltY: l Beau 5TALTE ®F ✓ y " CHRISTINE L COUNTY O_F 1 7 " Y MISSIO B e`foregoi g Inso� e was�ckrloysI dgcd before me this "I 1O ((1t my commis r Signature of Notary Public —State of Whenever the owner / contractor desires an inspection to be performed'•ro an r) a other lban the above or a St Lucie County Inspector, anew application form must be submitted and approx-t•d h...:.,,i St Lucie County Building Official or Building Code Supervisor BEF®11$ the subject inspection (s) is (are I'Ifit : ARMED C+r ] The St Lucie County Building Department may at any / all times visit t-n• iron action sits• to ensure compliance 'The St Lucie County$uildjng P.+ -_ tment may at any /all times visit OrOraon;•i -I, spa• to ensure compliance C23 and / or for the purpose of spot i': :lions to verifying construction act u,c:: t tnpliance with the construction documents / drawings. Failure to follow standard operating procedures for Inspections for tii B m, it County may negate any further approvals for you or your firm to perform this Hype of inspection. In tcdali i a, Incomplete or imaccw rate inspection reports may result in failed Inspections, work stoppage wut t u, • ermil expiration. All violators will be referred to Cite FL, ).P.jL Should you have any ctuastiona regarding this procedure, please contact t: uv u ' cic Conoty Building Department 0 iBuiilding Official or Bulldlmg Code Supervisor Print Name Signatuo-s — --- lDmte'