HomeMy WebLinkAboutSUBMITTED PAPERSALL APPLICABLE INFO UST BE COMPLETED FORAPPLICATIONTO BE ACCEPTED
Date: SCANNED
Permit Number: (7��f1JS0( L`l
BY
Lucie County
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential_
PERMIT APPLICATIONFOR:
�C/ ' ' 4.�.RR "� ux ar, .w � aae� k�'"•'a',,. sg wt, . >^. .: .i m.a
Address: 15""/0 �o � 0144re:e ira/l Port et ce E1- 3'/4,y2
Legal Description:
Property Tax ID#: 3 Vo 2 -610 ^Oo boo,
Site Plan Name:
►i
Project Name:
Setbacks Front Back: Right Side: Left Side:
Lot No.
Block No. % 2
(le�lU�e �Irf-�ar��c �f.r�u�er�a� w/fh (�Jc�-ems �l,�cU�rf—o�
11 J17 l C P , 0 0 o S Z MzU h r► � 2r nl Q.s h
ia►tional worK to De
E1HVAC
❑ Electric
errormea
unaertnis permit- cnecK aii
Gas Tank ❑Gas Piping _
Plumbing Sprinklers ❑
apply:
Shutters Windows/Doors
Generator ❑ Roof
❑
Total Sq. Ft of Construction: ' q 00 5 6t -
Cost of Construction: $ 2. 1-150 .
S Ft. of First Floor: _
Utilities:In Sewer 11 Septic
Name�Gi,� C:h gin. ;and 9V/�nC K �r B �r
Add Bess: 5 4f0' 6t O -e-1 f 1
City: erg 2 State.�
Zip Code: z Fax:
Phone No.
E-Mail:
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
Building Height:
Name: _J.0 .V.06, :1� l V'CY 41
Company:" �'; � F C'o/15 �� C 16917 10
Address: I4Ve
City: Po rf- e ! L-rCe State:-P—L
Zip Code: 3 F 4-1 5 Fax:
Phone No. 7?Z j l S iL0
E-Mail: 9Fco175+eVcfrV✓1 21 QGwlai 1, cp,-4
State or County License:
If value of construction is $2500 or more, a RECORDED Notice of Commencement is required.
DESIGNER/ENGINEER: _ Not Applicable
Name: _
Address:
City:
Zip:
Phone:
FEE SIMPLE TITLE HOLDER:
Name:
Address:
City:
Zip: Phone:
State
_ Not Applicable
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
City: State:
Zip: Phone:
BONDING COMPANY:
Name:
Address:
City:
Zip: Phone:
Not Applicable
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in accordance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review: room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
WARNING TO OWNER: Your failure to Record a Notice of Commencement may result in your paying twice for
improvements to your property. A Notice of Commencement must be recorded and posted on the jobsite
before the first inspection. If you intend to obtain financing, consult with lender or an attorney before
commencing work or recording vour Notice of Commencement:
Signature of Owner/ Agent/ Lessee
STATE OF FLORIDA
COUNTY OF � Y44�
The f g instr nt was acknowledge'd efore me
this^day of 20LY by
Personally Known _
Type of Identification
Commission No.
Revised 07/15/2014
yGYI � c Uer-�
Signature of Contractor/License Holder
STATE OF
COUNTY OF. J
The for ng instru nt was acknowledged b fore me
this ay of _ 20y
(Nkn�e Iffierson acknowledging) `
Public- State of Flo
Personally Known;$a,�o�luced Iden171tIvDIihONE
DAWN MILONE Type of Identification Pr� ` h'%: Notary Public - State of Florida
Notary Public - State of Florida ; • « :,� My Comm. Expires Mar 22, 2017
My C xpires Mar 22, 2017 f"' '' ° C
Qal Commission No. G %9, �B)on EE 877571
Commission � EE 877571 �'��� ,Bonded Through National Notary Assn.
Bonded Through National Notary Assn.
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEA TURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
o''d
n�)-ad�
PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR, SUBCONTRACTOR OR CANCELLATION OF PERMT
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR — Change of Contractor is to be signed and notarized by the property owner,
and the new contractor of record for the current permit. A new permit application must also be completed with new
contractor information and signature. A new Notice of Commencement must be filed in the new contractor's name
for job values greater than $2,500 ($7,500 if A/C Change -out). A recorded copy must be submitted prior to
commencing any work. There is a $50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR — Subcontractor changes are to be completed by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. There is a $50.00 fee for the Change of Sub -
Contractor.
CANCELLATION OF PERMIT — The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: i [l 117
Permit Number: NN.
oqa�
Site Address: 540(o (' ;,A ap, —rc-al
4 'i—� 011&1, r JCA0.) —1A C, State License SLC License
Original GC, subcontractor or wner/builder
rrws 'C'� State License SLC License
Ne�ubcontractor
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers, agents and employees from all
costs, fees or damages arising from any and all claims of action for any reason, which may arise as a result of this change of
contractor/subcontractor or cancellation of permit. A permit cannot be cancelled if work has been performed.
.0 51�-
SIGNATURE OWNER (or owner/builder) SIGNATURE GENERAL CONTRACTOR (or new GC, as applicable)
PRINT NAME �6rr"s PRINT NAME
State of Florida, County of St. Lucie County State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this The following instrument was acknowledged before me this
day o20], by day of 20_, by
who is personally,known to me who is personally known to
oi►lro produced_ n as ID. U(40 .1JU.ssa1or who has produced .. as ID.
of Notary
AHNA IN
to nG H
tqS
a aco
Revised 04/15/1 r i ,? Notary public •State CAM
"o;, MY Comm Expires °t Florida
,6 ; �1°�' Co missi Cec 20, 201n '
m
Bond
edthrou9h�n FF ' �'2aq
_ \ .�p•ar%HISS r, �1
Signature of Notary Date
OU N� y
F L o P. I D R
Planning & Development Services Department
Building & Code Regulations
2300 Virgh Avenge
Fort Pierce, Florida 34982
(772) 462-1553
OWNERBUILDER 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 for your use and occupancy. You
may also build or improve a commercial building at a cost not exceeding $75,000.00 as long as it is for your own
use or occupancy. You may not build or improve said structures for the purposes of selling or leasing that building.
If you sell or lease a building you have built or improved within one year after construction is complete, then a
presumption is created that it was built or improved 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. Your construction must comply with all ap ble
laws, ordinances, building codes, and zoning regulations. Initial
I understand that the building official and inspectors are not there to design or give advice on how Pet
the minimum code. Initial
I understand that as an owner -builder that any contract disputes with sub -contractors and I must be handled
in a civil court with the advice of an attorney. This department will not mitigate any contract disputes.
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 liabl@ ter the
cost of the license. Initial
I understand that if any person that is unlicensed and uninsured gets injured on my construction project -
they may be entitled to workmen's compensation. I could be held liable for all doctor, lawyer and related rp-dica1
cost, which could include loss of wages during recovery from their injury. Initial 1W
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
nj:q=
ridaStat Department of Professional Regulation. Signed and acknowledged on this
of 20.
OwnerBuild r Signature
STATE OF FLORIDA
COUNTY OF
T e for ' g instrument was acknowledged before me this day of 20 ,
who is personally known to me, or who has
"ucedV�_�1a4Q . �Pa%- »' STV• 0 as identi c io .
LASHAHNA IN6RAM
°p`�: Notary Public - State of Florida
S' a of Notary Type or Print Name of My Co(rSea}pins Dec 20, 2018
Title: Notary Public Commission Number ",9; �� Commission # FF 177249
' %° ��'• Bonded through National Notary Assn.
SLCPDSD Revised 05/15/2014
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: U ® ADDRESS:
I, P, rw' f r,% ° cz'- , am requesting that the above permit be renewed. I
undErstancl that I must schedule and pass all required inspections for the permit to be finaled. Further, I
understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a
passing inspection during any six month period during the renewal period. -
Justification COW4
OR CONTRACTOR SIGNATURE
is
Print Name
III b
DATE
STATE OF FL O A
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF J 20n-
gy,� WHO IS PERSONALLY KNOWN TO ME , OR
HAS PROVIDED;
AS IDENTIFICATION.
TE OF FLORIDA, Co ty of �- 0
'1ASHAHNA
INGRAM
Notary
F-�,ffl
Public -State of Florida
IGN O NOTARY SEA`
My Comm. Expires Dec20, 201B
Commission # FF 177249
Bonded through P!a!io,.a! "I
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
Example: [15 divided by 23=.65(0/o)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/212014