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Home My WebLink AboutSUBMITTED PAPERSDate: f Fee Due: rmit # Planning & Development. Services Building & Code Regulations Division 2300 Virginia Ave. Fort Pierce, FL 34982 (772)462-1553 �Cq &t .,,Cie County SPECIALTY PERMIT APPLICATION ❑ Electrical VI'lumbing 0 HVAC ❑ Fence ❑ Shed ❑ Demolition ❑ Gas ❑ Siding Seepage 2 for instructions and additional paperwork required for specialty permits 1. Location/Site Address: 4 -?-. 6' C w3gonha Ver rk A F-L .3 9 4 2. Parcel ID Number: 3 �3 a`17 - 0000 — 000 A Office Use Only Section Township Range Map Page nia Land Use Initials 3. Complete Description of Project or Work: h aog "'+'"Q (' ► �a /.I.) 4er 4. Owners Information 5. Contractors Name: p2 l ; 1 ho ms FL Reg Address: 1 •-4�,pp-nh(ayer City:' j p�p� State: rL County Busine; Zip: '?,44Phone: Phone; 6. Value of Construction: S to OWNER'S AFFIDAVIT: I certify that all of the information contained in this application is correct and that all work will be done in compliance with all applicable laws regulating construction and zoning. _11 PRINT OWNER ORCONTRACTORNAIE SIGN OF OWNER OR CONTRACTOR STATE OF FLORIDA, COUNTY OF S �. L ae-i t - r ACKNOWLEDGED BEFORE ME THIS DAY OF 20) BY d I a l G� ei WHO IS PERSONALLY KNOWN TO ME _J_/OR WHO HAS PRODUCED AS IDENTIFICATION. ' ,, I I/ ad Veer .`1 +! (SEUWETH 1. WALKER SIGNATUP& OF NOTARY TYPE OR PRINT NAME OF NOTARY Commission # EE 195640 �"--��'; .,e: Expires May 20, 2016 COMMISSION NUMBER Bwed TMuTroyFnin lnsumnee 8ow8s•7olo 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: A/C -HEAT REPLACEMENT WITH CONTRACT UNDER $7500.00 Revised 04/26/2010 I Planning & Development Services Department Building & Code Regulations 2300 Virginia Avenue Fort Pierce, Florida 34982 (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 applicable 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 ho to meet the minimum code. Initial I understand that as an owner -builder that any contract disputes with sub -contractors and I must be dled in a civil court with the advice of an attorney. This department will not mitigate any contract disputes. Initial QV I understand that if I compensate any person or company for work performed they are require to be licensed in this jurisdiction. If for some reason they do not possess a license, I may be responsible and lia a fo 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 medical cost, which could include loss of wages during recovery from their injury. Initial al r To qualify for this exemption under this subsection, an owner must personally appear and signthe 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 Zoning Department to the Florida State Department of Professional Regulation. Signed and acknowledged on this day of ffl0a of 20 /. 44 O Builder Signature STATE OF FLORIDA COUNTY OF S* L LLCi e— �2 The for instrulnent was acknowledged before me this —�4� day of 20�, by � 07 , W ► 1,l ;EV-L S who is personally known to me, or who has produced as identification. Si�e; �lza _ J 1 ve-C of Notary Type or Print Name of Notary (Seal) Title: Notary Public Commission Number EE HSWO ELIZABETH J. WALKER A.1 . Commission # EE 195640' SLCPDSD Revised 07/22/2010 �tk= Expires May 20, 2016 �+%R"` Bonded Tlw Tmy Fain Insurance 80038S•�019' Fort Pierce Utilities Authorifi°- "Committed To. Quality" Key Accounts 206 S. 6th Street NQUAor Fort Pierce, FL 34984-3191 Phone (772)466-1600 Fax (772)465-6984 Job Location: 1435 COPENHAVER RD Invoice Number: KA-5-13 Account Name: JODI R WILLIAMS PCN: 231324100000008 Contact Name: JODI R WILLIAMS LocID: / 0747-- Billing Address: 1435 COPENHAVER RD FORT PIERCE FL 34945 Phone: (772)462-1601 . Fax:( ) - Cell:( ) - Cust Type Residential City Limits Outside Description � F,ees 1 6/8 X 3/4" Water Meter and/or Service Installation $800.00 Water Security Deposit $60.00 Water New Account Setup Charge $40.00 Water Capital Improvement Charge W ERC's 1.00 $920.50 *Water Accrued Guaranteed Revenue Charge $0.00 Meter Verification Fees $0.00 Wastewater Security Deposit $0.00 Wastewater New Account Setup Charge $0.00 Wastewater Capital Improvement Charge WW ERC's 0.00 $0.00 *Wastewater Accrued Guaranteed Revenue Charge $0.00 Lien Fees 139.00 Construction Cost Estimate: a. Fees 0.00 0.00 ^v__� ,*W Wind lastewater AGRC fees are good untilahe end of the month 'If not received.by fhe end of the month new fees will:apply. Please contact our,ofriice for updated fees Description for service order: INSTALL 5/8 X 3/4" WATER METER W/SERVICE r Total Paid: / 'b Date Paid: `'r 1� DOWn Payment: $391.90 Invoice Total: $1,567.60 Check Number: Customers will be assessed wastewater charges the day they connect to the wastewater system or within 365 days from date wastewater Connection Charge is paid - whichever is first. The cost of the service line from the point of delivery at the property line to the house/building is the responsibility of the customer and is not included in this invoice. State laws require that a permit from the Health Department must be obtained prior to initiating a septic tank abandonment. Contact the Health Department at (772)873-4931. Construction cost estimates are based on current labor, equipment and material prices. Actual costs of construction will be determined at the completion of the project. Should unforeseen circumstances be encountered during construction, including but not limited -to adverse weather conditions and construction conflicts, the customer will be responsible for increased costs. Additional costs incurred by the customer shall not exceed fifteen (15) percent of the total estimated construction costs shown above. Estimated costs paid by the customer that exceed the actual cost of construction will be refunded by Fort Pierce Utilities Authority. Reviewed By: Joyce Easterday Key Accounts Specialist Date: 01/08/2013 Customer's Signature: Date: Printed Name: