HomeMy WebLinkAboutSUBMITTED PAPERSPlanning & Development Services
Building & Code Regulations Division
2300 Virginia Ave.
Fort Pierce, FL 34982
(772)462-1553
.7505-030 )
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SPECIALTY PERMIT APPLICATION.
❑ Electrical Plumbing ❑ HVAC ❑ Fence
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
Seepage 2 for instructions and additional) paperwork requir
ed
for specialty permits
1. Location/Site Address: ��/3 �S eT �/y J
9 `` ' ��
2. Parcel ID Number: `�e� 22C2 n(Ddad
Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
I Initials
3. Complete Description of Project or Work: 1,JFj Td r /AD
4. Owners Information �" 5. Contractors Information
Name: S') "" /'� �� '/v��� FL Reg/Cert #:
Address: `� �� ` County Cert#:
City: t State: �✓ % Business Name:
Zip: `�T Phone: Phone: Fax:
6. Value of Construction: $ ASD'ao
OWNERS AFFIDAVPr: I certify that all of the information contained in this app ation is correct and that 1 11 work will be done in
co p ance v�nth all applicable laws regulating cons d zo
PRINT OWNER OR CONTRACTOR N SIGNATURE OF OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 20� BY � !
WHO IS PERSONALLY KNOWN TOME OR WHO HAS PROD D V`kC� V ✓ c� ���
A ENTIFICATION. DAWN MILONE
Not �iYblic - State of Florida
e
OF NOTARY TYPE D PRINT NAME OF NOTARY • My c;lmm. Exr(ires Mar 22..2017
CQ(nmission # EE 877571
MI COMSSION NUMBER ••° ��"Bonded Through National Notary Assn.
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
'ST..LUCIE COUNTY'UTILITIES P.U, 728j,FT: PIERCE. FL'34982 ;-
�J NAME .A
St. Lucie County` - PCIS
05-16-2013
12 :21:36
AccT
14427/5360
sERVICE ADDxEss U1.�. � , ,. ,� � fv"
MENDES , JEAN M .
6013 SUNSET BLVDY�'�'`"
=ORT PIERCE
y . P
134982
VSON OLOCL
amount Tendered:
L BILLINGADDRESS ti,��
mount Paid:
518.00
range Due:
PHONE # , � 7 .I (; �MOVE INICLOSING DATE /%
'
0.00
a
lank YOU
This apphcation,hereby request.aitd authorizes the,Utilityto renderwater and/or sewage disposal _j
services to'the premises descAtd above in accordance with the Utilities present or futurp rates, -'
rules and -regulations, which by reference are made`a part of this contract Applicant agrees to pay
the Utility promptly for such services in accordance with the established rules and,regulations 4
er ID : , RODRIGUEZM
CUSTOMERS, DEPOSITS ARE NON NEGOTIABLE OR'TRANSFERABL
SOCIAL SEC/ {
F
FED ID
. SPOUSE SOCIAL SEC-.
OFFICE US� OI+FLY ' F
DATE RECEIVED CASK f �---
f C RECEIVED B,Vn
Planning & Development Services Department
Building & Code Regulations
o § a 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 applic le laws,
ordinances, building codes, and zoning regulations. Initial - 14/
I understand that the building official and inspectors are not there to design or give advice on how to meet
the minimum code. Initial xe✓
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 liale for the
cost of the license. Initial ,S 6-1 -
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 relato medical
cost, which could include loss of wages during recovery from their injury. Initial > - 1� ,
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
Zoning Department to the Florida State Department of Professional Regulation. S' ed and acknowledg on this
fgL day of of 20
Owner/Builder Siture
STATE OF FLORI ®dl� �''^ � Dew
COUNTY OF
The fore oin ins ent caged before me this 2-- day of 20 a,
by who is personally known to me, or who has
pro aced — 1. as identification.
I _ .�n�
Signature of Notary �, Type or PFINTRame of Notary (Seal)
Title: Notary Public Commission Number
SLCPDSD Revised 07/22/2010