HomeMy WebLinkAboutSUBMITTED PAPERSDate: Fee Receipt# TPermit #
Planning & Development Services
1 Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982 BY
(772)462-1553 ,Cie COG
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SPECIALTY PERMIT APPLICATION
❑ Electrical ❑ Plumbing ❑ HVAC Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address:
2. Parcel 1D Number,
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
Initials
3.
4. Owners
Name:
Address: c—)(_A ') ( � I IV
City: T1
Zip:
3-1:n ?�4=
or Work: _I�SI � l'� t�
nCE S
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5. Contractors Information
FL Reg/Cert #:
( Side County Cert#:
State: �� Business Name:_
-77a nn
Phone: dr Phone: Fax:
6. Value of Construction:_cayneLa
OWNER'S AFFIDAVIT:
IS
V' v�rr-• oa
G0
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work will be done in
)jc complianc with all applicable laws regulati g o stru Kionahon'
PRINT O OR CONTRACTOR NAME SIU14 O ER'OR-C36NTRAI&TOR
STATE OF FLORIDA, COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 20BY
WHO IS PERSONALLY KNOWN TO ME OR WHO HA PRODUCED
ENTIFICATION.
E OF NOTARY
COMMISSION NUMBER
i
TYPE OR PRINT NAME OF T Y
(seal)
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
EXEMPT: AIC-HEAT REPLACEMENT WITH CONTRACT UNDER $7500.00
A Planning& Development
p Services Department
Building & Code Regulations
2300 Virginia Avenue
,s M1 rr Fort Pierce, Florida34982
(772)462-1553 -
OWNER/BUILDER AFFIDAVIT DISCLOSURE STATEMENT
F.S. 489.103 (7) EXEMPTIONS
State law requires construction to be done by licensed contractors. You have applied for a permit under an
exemption to that law. The exemption allows you, as the owner of your property, to act as your own contractor even
though you do not have a license. You must provide direct, on -site supervision of the construction yourself. You
may build or improve farm outbuildings, a one -family or two-family residence or a commercial building at a cost of
under $75,000.00. The building or residence must be for your own occupancy. It may not be built or substantially
improved for sale or lease. If you sell or lease a building you have built or substantially improved your self within
one year after the construction is complete, the law will presume that you built or substantially improved it for sale
or lease, which is a violation of this exemption. You may not hire an unlicensed person to act as your contractor or
to supervise people working on your building; it is your responsibility to make sure that people employed by you
have licenses required by state law and by county or municipal licensing ordinances. You may not delegate the
responsibility for supervising work to a licensed contractor who is not licensed to perform the work being done.
Any person working on your building who is not licensed must work under your direct supervision and must be
employed by you, which means that you must deduct F.I.C.A. and withholding tax and provide workers'
compensation for that employee, all as prescribed by law. Your construction must comply with all appli ,
ordinances, building codes, and zoning regulations. Initial
I understand that the building official and inspectors are not there to design or give advice ont t eet
the minimum code. Initia
I understand that as an owner -builder that any contract disputes with sub -contractors and I must be handled
Initial
I understand that if I compensate any person or company for work performed they are required to be
licensed in this jurisdiction. If for some reason they do not possess a license, I may be responsible and libMfr
cost of the license. Initial
I understand that if any person that is unlicensed and uninsured gets injured on my construction proj -
they may be entitled to workmen's compensation. I could be held liable for. all doctor, lawyer and relate
cost, which could include loss of wages during recovery from their injury. Initial
To qualify for this exemption under this subsection, an owner must personally appear and sign the building
permit application and initial the above.
I hereby acknowledge that I have read and understand the above disclosure statement and that I further
understand that any violation of the terms of the owner/builder exemption shall be reported by the Building and
Zo, ng Dep ent to the Florida S t Department of Professional Regulatio ed d a�oe n this
Rio day of, of 20
STATE OF FLORID ..aptARYpi
COUNTY OF'�•
The strum was ac w before me this day of _ • ����
A
by who is personally kno, ,E „ °.� n6�i�yM�lo
pro ced as ide tificatioh:.;......
C° ?L F S/ HF
BOnde M% x.0/, ate Of
AZ dThr0U9h�`F�Mar??F?rraa
lgnature o otary Type or Print Name of Not "'� (S ���
Title: Notga Public Commission Number
SLCPDSD Revised 07/22/2010 u q
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