HomeMy WebLinkAboutSUBMITTED PAPERSDate: D '/'FN I Fee Due: -XV - C U 1 Receipt# I Permit # /� `X
Planning & Development Services
Building & Code Regulations Division
2300' Virginia Ave.:
Fort Pierce, .FL 34982
(772)46271553
............... ...................... ..._..__...._._............... _..... .�....._..._._......... __...._........ _.......... _... _...... _......... .......... _... __.... SPECIALTEFE-11, A .
PMICATTO.._.........................................._....._.....__....._....._......__....... -- _ _—
❑ Electrical ❑ Plumbing ❑ HVAC ❑ Fence ..
s
❑ Shed ❑ Demolition ❑ Gas ❑ Siding
See page 2 for Instructions and additional paperwork required for specialty permits
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1. Location/Site Address: S li Ch �C1i J e_
2. Parcel ID Number: i) l P b9 - h ig ^ h D o '3
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Office Use
Only
Section
Township
Range
Map Page
Zoning
Land Use
IniBals
3. Complete Description of Project or Work: hr,,Y_- r) fN �D ► ,h.e"—
4. Owners Information 5. Contractors Information
Name: U�c� �`F FL Reg/Cert #:
e
Address: ,`i S L)-i N, f c k County Cert#:
City: �� - :?1e1'Cr� State: F'L_ Business Name:
Zip: 34 ,q U Phone: Phone: Fax•
6. Value of Construction: S
OWNEWS AFFIDAVIT: I certify that all of the information contained in this application is correct and that all
work will in
compliance with.all applicable laws regulating constructioan zoning.
�G A'
PRTwT nwNFiR DR C nNTR ACTOR NAM]t . P SIGNATURE OF OWNER OR CQRTRACTOR
STATE OF FLORIDA, COUNTY
ACKNOWLEDGED BEFORE ME THISe772� DAY OF
WHO is PERSONALLY KNOWN TO ME OR WHO HAS
COMMISSION NUMBER
BY -j)14)VC J��y
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. Mk -YOU INTEND TO OBTAIN FINANCING, CONSULT wrm YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE.OF COMMENCEMENT.
EXEMPT: A/C -HEAT REPLACEMENT WITH CONTRACT UNDER 57500.00
Revised 04/26/2010
„t Planning & Development Services Department
Building & Code Regulations
n� s” 2300 Virginia Avenue
x 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--alcensed 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 b law. Your construction must com l- with -all a - licable laws— - -- " " "
pP Y p Y pP
ordinances, building codes, and zoning regulations. Initial*co�
I understand that the building official and inspectors are not there to design or give advice on how to meet
the minimum code. Initia
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.
Initialu
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 liable for he
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 me
cost, which could include loss of wages during recovery from their injury. Initi
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
A?td
Dep t to the Florida S to Department of Professional Regulation. Signed and acknowledged on this
ay of of 20
Owner/Bul der Signature
STATE OF FLORIDA �-
1
COUNTY OF ��4-L&-
T oing instr ent was acknowledged before me this cP day
of ,
�_
ore
by who is personally
kno to me, or who has
educed Y-
as identification.
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• `�Ir
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Signature o tary T or Print Name of
otary (Seal)
Title: NotWykublic Commission Number
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"--,�m-0
Cho=
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SLCPDSD Revised 07/22/2010
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O*W. ST. LUCCQUNTY UTILITIES B0K728,; . PIERCE, Ft 34982
SEWER
I ,
NAME
..METER SZ-.:.i z
D ACCT. #
3
Vq d: I k SERVICEADDREW
SECURITY Dul SECU7,
$
SERVICE FEEi
.4'
SAME DAY 5 FE 1 _
SUB1, K5Z
SUBDIVISION BLOC
OVEl1TIMtAE!-
METER INSTAL CFC/WATERi.
It" L S., BILLING ADDRESS.
FPUA CFC
PHONE M .0 IN/CL S7G DATE
CFC/SEWER.
This application hereby request and authorizes the Utility to render water and/or sewage disposal
GUAR. REV.
services to,the, premises described. above in accordance I ith the Utilities present or futurd rates,
rules and regulations, which by reference -- 1i / i
e are mla/de'ii pa of this; contract. Applicant agrees to pay
LATERAL j I
the Utility promptly for such services in accordance,with the established rules and regulations.
$ TOTAL CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
CUSTOMER. SOCIAL SEC/.
SIGNATURE FED ID
NAME OF SPOUSE SPOUSE SOCIAL SEC.
OFFICE USE ONLY i
X
DATE RECEIVED J c;- -_..'CASH CHK # RECEIVED BY