HomeMy WebLinkAboutSUBMITTED PAPERSOFFICE USE ONLY: ( I / �_r
DATE FILUD: I
PLAN REVIEW FEE:
rnwrTTRRENCY FEE:
RECEIPT NO.:
RECEIPT NO.:
PERMIT NUMBER
CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED
PLANNING & DEVELOPMENT SERVICES DEPARTMENT
BUII.DING & CODE REGULATIONS DIVISION
2300 Virginia Avenue `,cz
Ft. Pierce,
FL 35582-5652 S'� `�c/e yN �o
� CoUntY
APPLICATION for BUII.DING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION
1. LOCATION/SITE ADDRESS: �U%1• �- lid�eV,
2. PROJECT NAME: SITE PLAN NAME:
3. PROPERTY TAX ID #: .;4V612 -•f h9 — 090 —000 —/
4. LEGAL DESCRIPTION (attach extra sheets if necessary):
5. PLAT BOOK 6. PAGE NO. 7. BLOCK NO. 8. LOT NO.
9. PARCEL S12E (ACRES/SQ FT.): Vz.1 LOT DRAENSIONS: 90
i0. COMPLETE DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTIVITY: mil- 11 / G ado
SETBACKS (ACTUAL) FRONT: BACK: RIGHT SIDE: LEFT SIDE:
TYPE OF CONSTRUCTION (Check all appropriate boxes)
[ ] NEW CONSTRUCTION
[ ] RESIDENTIAL
OTHER (SPECIFY) A
[ ] EXPANSION/ADDITION [ ] INTERIOR RENOVATION
[ ] COWv1ERCI4,L [ ] INDUSTRIAL
DESCRIPTION OF PROPOSED USE: D
SQ. FT OF CONSTRUCTION: 4Gla 15. SF. FT 1st FLOOR
-f
VALUE OF CONSTRUCTION: S
The value of construction is used to determine the amount of permit fees to be assessed. St Lucie County reserves the rigbt to question and/or modify the indicated
value of construction if it is demonstrated that the submitted figures are not consistent with similar types of construction activities. If the value is $2500 or more, a
RECORDED Notice of Commencement must be submitted with this application.
SLCCDV Form No.: 001-02
UPDATED 6/25109
OWNER INFORMATION
NAME:
ADDRESS: 6 7
CITY: STATE: i� ZIP:
PHONE (DAYTU E): (VP) 444 -6,712 Email: --I.-4r-f %� � ��'1► - �h'?
IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED ABOVE, PLEASE
FILL IN NAME AND ADDRESS BELOW.
FEE SIMPLE TITLEHOLDER:
ADDRESS:
CITY: STATE: ZIP:
PHONE (DAYTIME): (---j
CONTRACTOR INFORMATION
ST. of FL REG.CERT #:
BUSINESS NAME: _
QUALIFIERS NAME:
ADDRESS:
CITY:
PHONE (DAYTIME):
ADDRESS:
CITY:
PHONE (DAYTHME): C__j
BONDING COMPANY:
ADDRESS:
CITY:
MORTGAGE LENDER:
ADDRESS:
CITY:
STATE:
FAX NO.
ST.
STATE:
STATE:
ST.
CERT #:
Email:
Ar
"AF
Ar
IMPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification
it will be voided and returned to you by mail.
,CERTIFICATION
This application is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate of capacity,
if applicable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit and that all
work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
may be required for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS,
AND AIR CONDITIONERS, FENCES, ETC., not otherwise included with this building permit application.
St. Lucie County makes no representation that its granting of a permit will authorize the permit holder to build the subject structure
which is in conflict with any applicable Homeowner Association rules, bylaws or any covenants that may restrict or prohibit such
structure. Please consult with your Homeowner's Association and review your deed for any restrictions which may apply.
The following building permit applications are exempt from undergoing a full concurrency review: room additions, accessory
structures (all types), swimming pools, fences, walls, signs, screen rooms, utility substations & accessory uses to another non-
residential use.
NOTICE TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENTMAY 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 YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
NOTICE TO APPLICANT: IF IT IS NOT YOUR RIGHT, TITLE, AND INTEREST THAT IS SUBJECT TO.
ATTACHMENT: AS A CONDITION OF ISSUANCE OF THIS PERMIT, YOU PROMISE IN
GOOD FAITH TO DELIVER A COPY OF THE CONSTRUCTION LIEN LAW NOTICE TO
THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT.
OWNER OR CONTRACTOR SIGNATURE
STATE OF FLORIDA - "
COUNTY OF.
The foregoing instrument was acknowledged before
me this � , day of 20 l '
-Th
by LLQ:�J
who is personally k(nown- or has produced
1 v was identification.
Si a of Notary
fis!31; NfDO852587
March 22, 2013
MY COMMISSION #I DD 852 %°+ ' �.�'.�'• ubiicUndenhiters
EXPIRES: March 22.20
Bonded ThN Notiry PuNo Undo.. -
CONTRACTOR SIGNATURE
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was acknowledged before
me this day of 40 ,
by
who is personally known or has produced
as identification.
Signature of Notary
Commission No. (Seal)
TWij(2)_SMRn'MS ARE REQUIRED. EACH SIGNATURE MUST BE NOTARIZED. IF APPLYING FOR
THIS BUILDING PERMIT AS AN OWNERIBUILDER, THE OWNER MUST PERSONALLY APPEAR TO SIGN
THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THIS APPLICATION.
OWNER BUILDER AFFIDAVIT WILL BE REQUIRED FOR ALL OWNER/BUILDER APPLICANTS.
For specific instructions see appropriate permit checklist.
" BOARD OF
COUNTY
COMMISSIONERS
NOTICE TO ALL CONTRACTORS
EFFECTIVE IMMEDIATELY
OCTOBER 1, 2010
NING & DEVELOPMENT
iVICES DEPARTMENT
Building & Code
tegulation Division
As stated in Chapter 19 of the'Florida Building Code all concrete placed on a
specific site must conform to a minimum compressive strength. In addition to
this, your design professional may have designed your project with increased
conditions for compressive strengths in mind.
Effective immediately we will require contractors and owner -builders to
submit copies of the batch tickets from your concrete company for all concrete
placed within our jurisdiction in the un-incorporated areas of St Lucie County.
These tickets must be submitted prior to the next series of inspections as
listed on your inspection card. Be sure that your permit number has been
added to assure proper review and. filing.
Thank you,
Ken Arnold
Building Official
CHRIS DZADOVSKY, District No. 1 - DOUG COWARD, District No. 2 - PAULA A. LEWIS, District No. 3 - CHARLES GRANDE, District No. 4 - CHRIS CRAFT, District No. 5
County Administrator — Faye W. Outlaw, MPA Website: www.stiucieco.oro
2300 Virginia Avenue . Fort Pierce, FL. 34982-5652
PERMITTING AND ZONING: Phone (772) 462-1553 FAX (772) 462-1735
CONTRACTOR LICENSING: (772) 462-1672 FAX: (772) 462-1148- CODE ENFORCEMENT: (772) 462-1571 - INSPECTIONS: (772) 462-2165
FAX: (772) 462-6443
BOARD OF
COUNTY
COMMISSIONERS
NOTICE TO CONTRACTORS
PLANNING & DEVELOPMENT
SERVICES DEPARTMENT
Building & Code
Regulation Division
As of July 1, 2010 St Lucie County Building Department will require the following items
for submittal with all Building Permit Applications and Vegetation Permits.
Residential Construction:
Two (2) sets of the following:
Survey
Sealed Construction Plans
One (1) Vegetation Permit application with one (1) set of Construction plans & survey.
Commercial construction:
Three (3) sets of the following:
Survey
Sealed Construction Plans
Electronic Copy of Construction Plans
One (1) Vegetation Permit application with one (1) set of Construction Plans $ survey or
Site Plan*
For additional Information please contact the Permitting Department at (772) 462-1553
*If the proposed construction entails a drive-thru or if the proposed building will exceed 6,000
square feet, it will be necessary to obtain site plan approval prior to submitting a building permit
application. Please contact the Planning Development Services Department at (772) 462-2M for
further Information.
-MS DZADOVSKY, District No. 1 • DOUG COWARD, District No. 2 • PAULA A. LEWIS, District No. 3 o C11ARLES GRANDE, District No. 4 . CIBUS CRAFT, District No. 5
County Administrator— Faye W. Outlaw, MPA Website: www.stlucieco.org
2300 Virginia Avenue • Fort Pierce; FL. 34982-5652
PERMITTING AND ZONING: Phone (772) 462-1553 FAX (772) 462-1578
CONTRACTOR LICENSING: (772) 462-1673 • CODE,ENFOR462MEN : (772) 462-1571 . INSPECTIONS: (772) 462-2165
A
.,r , , _F EF Planning & Development Services Department
�� . - �. r'"' ` Building and Code Regulations Division
2300 Virginia Ave
• I • A Ft. Pierce FL 34982
(772)462-1553
Notice to Contractors
On August 6,1996, the St. Lucie County Board of County Commissioners approved a series of amendments to'
the existing regulations governing the construction of single-family homes in a Recreational Vehicle Park.
Specifically, these regulations require the following:
o All exterior wall construction must have a minimum fire rating of one (1) hour;
o The maximum amount of fire rated wall openings, in any side wall, shall not exceed 1 0% of the total
wall area;
o All construction drawings submitted for a building permit approval, must be certified by a Registered
Florida Professional Engineer or a Registered Florida. Architect, that the design of the building meets the
fire protection requirements of this Code.
If there are any questions, please contact the Building Inspection Section at 772462-1553.
• Instructions
Please complete all information in the space provided. All information must be printed (use black or blue ink
only) or typed. Pencil will not be accepted.
All applications for Building Permit are to be submitted to the St. Lucie County Code Compliance Permitting
Department, 2300 Virginia Avenue, Fort Pierce, FL 34982. All applications for building permit must be
complete and filed with the Department before 4:30 PM each business day. No applications will be accepted
for processing after 4:30 PM. For an application submission to be determined to be complete, all required
materials must be present at the time of submission. Refer to St. Lucie County Building Permit Submission
requirements (form SLCCDV-010-00), which describes the required materials that must be submitted with each
application, based on the type of applications. If you need any assistance in completing this application,. please
contact the Code Compliance Permitting Department (772) 462-2167, during regular office hours (8:00 AM —
5:00 PM), Monday through Friday.
St. Lucie County Resolution 94-128 (effective October1,1994) provides that for new construction projects, all
commonly associated sub -permit activities (Plumbing, Electric, HVAGMechanical, Roofing, Gas etc.) will be
issued at the time the primary Building Permit is issued. In order for the Application for Building Permit to
be determined as complete, this application must include a signed ORIGINAL Sub -Agreement Form
(SLCCDV Form No. 002-00) for each of the sub -contractors to be used on the project (a Xerox copy of
the signatures will not be accepted) and one ORIGINAL copy of the Sub -Contractor Summary Report
(SLCCDV Form No. 0003-00). Copies of these required forms are included with this application Additional
copies of these forms may be obtained from the Code Compliance Permitting Department during normal
business hours or may be printed from the permitting web site. http•//www.stluciecd.org/Pages/permitap sn html
At the time the primary Building Permit is issued, all required sub -permits will also be issued. No application
-for Building Permit will be certiSed as complete, nor will any Building Permit be issued, unless there is a
complete identification of all sub -contractors expected to be associated with the proposed building
activity. In the event that you elect to change one or more of the indicated sub -contractors following the
issuance of this building permit, this may be accomplished by submitting a written request and new signed Sub -
Contractor Agreement forms for those sub -contractors you are changing.
The information to be provided with this application includes: (Numbers correspond to the numbered
1. Location/site
Indicate the street address, or general location, of the property on which the building activity is taking
Address
place.
2. Project & Site
Indicate the name of the owner (if residential) & the name of the business (if commercial). Indicate the
Plan Name
name of the site plan (if applicable), where the building activity is taking place.
3. Parcel ID Number
Indicate the Property Tax Identification Number for the property on which the building activity is taking
4. Legal Description
place.
Provide a complete legal description, of the property under Building Permit review. This legal description
may be attached as a separate sheet if descri lion if too lengthy to fit in the space rovided.
5. Plat book
If applicable, indicate the official Plat Book reference for the property on which the building activity is
proposed.
6. Page No.
If applicable, indicate the Page Number of the official Plat Book reference, for the property on which the
building activity is proposed.
7. Block No.
If applicable, indicate the Block Number for the property on which the building activity is proposed. This
can be found on the legal description of the property.
& Lot No.
If applicable, indicate the Lot Number for the property on which the building activity is proposed. This can
be found on the legal description of the ro
9. Parcel Size
Indicate the total area of the property under building permit application. For property less than one acre,
only the square feet need to be indicated. For property greater than one acre, both acres and square feet
need to be provided. Indicate all lot dimensions.
10. Description of
Completely describe the building activity under permit application.
Project
11. Setbacks (Actual)
For properties less than ten (10) acres, indicate all building setuacxsiue-m conuois to we prauuQua piuya■.y
lines. For properties greater than ten (10) acres, you may indicate field measarable building tie-ins in lieu of
roperiy line setbacks.
Check the appropriate boxes that describe the type of construction being proposed. This information is
12. Type of
Construction
13. Description of
required for the issuance of the Certificate of Capacity.
Briefly describe the proposed use associated with this application for building permit. This information is
Pro osed Use
required for the issuance of a Zonin Compliance.
14. Sq. Footage of
Indicate the TOTAL square footage ofthe building under permit application.
Construction
15. Sq. Ft/1 F1oor
Indicate the 1' floor square footage of all buildings under permit application. This is required to verify
16. Value of
maximum lot coverage.
Indicate the total value of the construction work to take place. Total cost of construction includes all material
Construction
and labor costs associated with the building/construction activity. The value of construction is used to
determine the amount of permitting fees to be assessed. St Lucie County reserves the right to question
and/or modify the indicated value of construction if it is demonstrated that the submitted figures are not
consistent with similar typps of construction.
Indicate the name, address & phone number of the owners of the property on which the proposed building
17.Owners
information
activi is. to take place.
Indicate the name, address, & phone number of the Qualifier as well as the State of Florida (if
I S. Contractors
Information
applicable) ) and St. Lucie County contractor's registration numbers for the proposed activity,
19. Architect/Engineer
Indicate the name of the Architect or Engineer of record who has prepared the building plans being submitted
for permit.approval.
20. Bondin Com any
Indicate the name of the Bonding Com any, if applicable.
Indicate the name of the Mortgage Company, if applicable.
21. Mortgage
Company
St Lucie County Resolutions 94-119 and 94-128, establish the required Plans Review and the Certificate of Capacity Fees. These fees
are due and payable upon submission of this application according to the following schedule:
Plans Review Fee Concurrence Review
Single Family Residence $250 (contractor) $350 (owner builder) $25
Two -Family Residence $500
Three or more units Value based plan review fee $25
*Please see permit fee schedule effective Oct 15,2006 for other fees
* Does not include Concurrency Review Fees due as part of the site plan review process, if required.
Upon the filing of this Application for a Building Permit you will be assigned a Permit Number. Please use this Permit Number when
making any inquiries or picking up your permit. When your permit is ready for pick up, you will be called. If your permit is not
picked up within 60 days of notification, it will be voided and returned to you by mail.
For new residential and commercialrmdustrial construction, a Driveway Permit and a Storm Water Permit may be required. For storm
water information, contact the Code Compliance Department at (772) 462-1553; for driveway information contact the Road and
Bridge Department at (772) 462-2511.
Following the issuance of this building permit the scheduling of required inspections may be made by calling (772) 462-1261.
Special Notice to all Applicants for Building Permit
Where fill is used, the PROPERTY OWNERS shall be responsible for assuring adequate drainage so
adjacent properties will not be adversely affected. (St. Lucie County Land Development Code, Section
7.04.01)
Planning & Development Services Department
BUILDING & CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FT PIERCE, FL 34982
(772)462-1553
JUNE 25, 2009
NOTICE TO ALL BUILDING PERMIT APPLICANTS
EFFECTIVE EMDIATELY we will require all residential and commercial building permit applications
(including additions, expansions, and interior remodeling) that propose to use central water and/or sewer to
submit the following with their building permit applications
A copy of the paid utility service receipt for water and/or sewer.
EFFECTIVE IMMEDIATELY we will require all residential and commercial building permit applications
for new construction to submit the following with their building permit application:
A copy of the paid utility service receipt for electric or a letter from the electrical provider that
electric will be available for the location.
NO EXCEPTIONS.
SLUDS Revised 06/092010
Planning'& Development Services Department
BUILDING & CODE REGULATIONS DIVISION
2300 VIRGINIAAVE
• R I D A FT PIERCE, FL 34992
(772)-462-1553
FROM: BUILDING & CODE REGULATIONS DIVISION
TO: ALL PERMIT APPLICANTS
RE: DISCLAIMER
WITH REGARD TO PERMITS and their effect on any HOMEOWNERS
ASSOCIATION RESTRICTIONS please, be reminded that: -
St. Lucie County makes no representations that its granting of a permit will
authorize the permit holder to *build the subject structure which is in conflict with
any applicable Homeowner Association Rules, Bylaws or any Covenants that may
restrict or prohibit such structure
PLEASE CONSULT WITH YOUR HOMEOWNER'S ASSOCIATION OR REVIEW YOUR
DEED FOR RESTRICTIONS WHICH MAY APPLY.
SLCPOS Revised 06/09/2010
11_
OFFICV USE ONLY JP #:
SECTION
TOWNSHIP
RANGE
MAP NO.
ZONING
LAND USE
LOT CVG %
TAZ NO.
FLOOD ZONE
FIRM MAP #
1ST FLR ELV
MAX HGT
CONST TYPE
OCCUP TYPE
MAX OCCUP
# OF FLRS
WATER
SEWER
SPRDWd ERS
STORMWATER
LOT OF REC
Before 111990
LOT OF REC
After 1/1990
LOT SPLIT
REQUIRED
LOTSPLrr
ROVED
REPORT
CODE
HABITABLE
AREA
RADON
FEE
PERMIT
FEE
LIBRARY
IMPACT
FEE
PUBLIC BLD
IMPACT FEE
CORRECTION
PUBIC BLD
IMPACT
FEE
GENERAL
PARKS
M PACT
FEE
SCHOOL
IMPACT
FEE
ROAD
IMPACT
FEE
CREDIT
Y
N
LAW ENF
RvIPACT
FEE
FIRE/EMS
IMPACT
FEE
DRIVEWAY
REQUIRED
Y
N
DRIVEWAY
FEE
ADMINISTRATIVE
VARIANCE FEE
SPECIFY
SUBS
REQUIRED
MECHANIC ROOF
ELECTRIC GAS
PLUMBING
NON -CONFORMING
LOT OF RECORD
FEES
MISCELLANEOUS
FEES
DATE SENT TO ADDRESSING:
REVIEWS
FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR
REVIEW
PLANS
REVIEW
VEGETATION
REVIEW
SEA TURTLE
REVIEW
MANGROVE
REVIEW
DATE
RECEIVED
DATE
COMPLETED
INITIALS
Lai�' - Y -'•�
St. Lucie'��:.,L-nty
Building & Zoning Department
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 how o meet
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 —7j5—
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 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 --�—
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. Signed and acknowledged on this
/Ai day of of 20
Owner/Builder Signature
STATE OF FLQR�DA ��
COUNTY OF �}� cA
The foregoing ins ment was acknowledged before me this 12Kday of4-c"Mmd'o I ( ,
b who is nermnally known to me, who has
prod uced = l —C� identification.
Signature of Notary Type or Print Name of Notary (Seal)
Title: Notary Public Commission Number
MI
MY COMMITS ION # 0 85258,
_* °g EXPIRES, March 22. 2013
lFg �; public Undo
BondedThNNuteryiYrtftsra
e.,c�
-
F L O R I U A
ST. LUCIE COUNTY
BUILDING & ZONING
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
772-462-1553
FILLED LANDS AFFIDAVIT
I, the undersigned, am the owner of the fo lowing described property:
V uc-ca (-10(
(Tax ID/Legal description/Address)
for which I have applied to St. Lucie County for a Final Development Permit. In accepting
this Final Development Permit, BP Number , I acknowledge that as owner of
the above described property, and in accordance with Section 7.O4.O1(D), St. Lucie County
Land Development Code, I shall be responsible for assuring adequate drainage so that the
immediate community WILL NOT be adversely affected. I further acknowledge that in
granting this permit for the development of this property, St. Lucie County is neither obliged
nor liable to provide for, or maintain in any form, adequate drainage off my property which
will not adversely affect the immediate community.
Property Owner Name Property Owner Signature Date
STATE OF FLORIDA, COUNTY 01 Crl i�
ACKNOWLEDGED BEFORE ME THIS I DAY OF 120 1, I
BY`A�\®lS IYA7S \1�r S WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED
L 1 OAS IDENTIFTCAI'I n \ p
�.
XA� M
SIGNATURE OF NOTARY
NOTARY PUBLIC TITLE
TYPE OR PRINT NAME OF NOTARY
(SEAL)
COMMISSION NUMBER
��P"I"
II
DAWN MILON�
iMYCOMMISSION # DO 8S25Si
EXPIRES: March 22, 2013Rf` Banded Thor NOIM Nblia Undsrwdt'm
k _3
Fort Pierce, FL 34982
772-462-2172 Fax 772-462-6443
CERTIFICATE OF TERMITE TREATMENT
CONSTRUCTION SOIL TREATMENT
PERMIT #: S" 6-11010 VJOB ADDRESS: �"9'D 7 'YOr-e-60- b r,,
BUILDER/CONTRACTOR: 6 0o -cQs
PEST CONTROL CONTRACTOR: �5:�2 LL2's
PEST CONTROL LICENSE #: J_-2- J I
We, the undersigned, hereby certify that we have pretreated the above described construction for
subterranean termites in accordance with the standards of the National Pest Control Association.
Square feet if area treated:
Percentage of solution: / O
Date of Treatment:
L,-_ Footings�
fist Treatment
Re -Treat
Driveway
1st Treatment
Re -Treat
Other
1st Treatment
Re -Treat
Chemicals used: 156*7;:7'Cr6
Total gallons used:
Time of Treatment:
Slab
vie` Treatment
Re -Treat
Pools
1st Treatment
Re -Treat
Perimeter for Final Inspection
67"S' ature of xt inator
Note. There must be a completed form for each required treatment or re -treatment and this form must be on the job
site to be picked up by the inspector at time of each inspection or the scheduled inspection will fail and a re -inspection
fee charged.
FBC104.2.6 Certificate of Protective Treatment for prevention of termites. A weather resistant jobske posting board
shall be provided to receive duplicate Treatment Certificates as each required protective treatment is completed,
providing a copy for the person the permit is issued to and another copy for the building permit files The Treatment
Certificate shall provide the product used, identity of the applicator, time and date of the treatment, site location, area
treated, chemical used, percent concentration and number of gallons used, to establish a verifiable record of
protective treatment. If the soil chemical barrier method for termite prevention is used, final exterior treatment shall
be completed prior to final building approval.
St Lucie County requires for the final inspection for CO, a Permanent Sticker to be placed on
the electrical Panel box cover, listing all the treatments and dates of applications.
53370622
Plant-
Begin Loading.--]
---------- To4ob:
Arrive Job: `
-Start Unload-
Finish Unload:
Leave Job:
Return Plant:
Customer Code: Customer Name: Customer Job Number: Order Code / Date:
CA'SM.'505 1092—DONNIE F A R MIE R 67 01/27/11.
'I'Project,Code: Project Name: Project PA. Number:',- order P.O. Number.
7 A -1 �S z;, 0
Ticket Date: Delivery Address: Map Page: Map/Row/Column:
59()?,, YUCCA, F1 P I E RC
Delivery Instructions* Dispatcher:
INDIM' R I VER EA3T. TLougl1lin
Ticket Number:
3 1332264
Due On Job:
Slump:
Truck Number:
Driver Number:
Driver Name:
End Use:
13.- 30
5.
-3
1002,17.) 4
1 o,:,3 3,4
1 '1 MONROE
UNASS I GNED'
LOAD CUMULATIVE ORDERED
QUANTITY QUANTITY QU MATERIAL CODE PRODUCTION DESCRIPTION
io. 00 1 Q. c) v 10.(-00 li&3497 300(--) R E G
1. 001 FUEL SURCHARGE
UOM I UNIT PRICE I AMOUNT.
YD3 75.00 75C). 0C
P C, 20. 00, 20. CX
..L. oo 12.02749 ENVIRONMEWrAL CHARG?E 10.00 10. 00
SALES TAX. 5 0'. 7 G
T4JTAL, AMOUNT, FOR TH I S TJCKET P401- D,JCLUDING STANDBY CHARGES:. 83(--j0 7(--j
7Cash £e.I Check # Auth Code: Signature of Driver Receiving Cash: Cash Recdjved: Total COD Order Amount to Collect
Without Standby Charges:
Check
7ICharge 830. It:
Comments:
WATER ADDED: rGAL YARDS IN DRUM:
EIVED WHEN ADDED.
REC
SIGNATURE
FEB 0 7 2011 CURB LINE CROSSED AT 9YVNER'S/AGENT'S REQUEST:
SIGNATURE
Q LOAD WAS TESTED BY:
Notice: Our drivers will make every effort to place materials where the customer designates, but the SPECIAL TERMS: Any water added is at customers own risk. If water is added on job, concrete strength.
Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guaranteed. WARNING: Product may cause skin and/or eye irritation. CAUTION: Material
terms of sale and delivery and accepts concrete as is. Due to important factors which are, out of our may be hazardous to your safety and health. Please refer to the backside of this ticket for important,
control after delivery, this Company will not accept any responsibility for the finished results. No credit for safety handling information, and to the material safe data sheets for additional information.
returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us in writing AUTHORIZE • SIGNATURE:
within one business day after the receipt of materials.
68UNIVERSAL PREV TRKt INVOICE LOAD NUNN 1
This Delivery Ticket incorporates herein ' reference Buyer's previously executed C '-t Application, if wiy, SePt_er's Standard
Terms and Conditions, Seller's (quotation tny, and Seller's Order Confirmation (inc ng limitations of warranties), as if fully
set forth on this Delivery Ticket ('.Agreement"). Seller will provide the Standard Terms and Conditions upon request. Buyer agrees
that. unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees
to ,pay in. accordance with the Agreement.
AGGREGATE / CEMENT % CONCRETE PRODUCTS
Aggregate products are naturally occurring materials limestone, dolomite, granite, volcanic rock, sand,. gravel, and
other sil_i.ceous materials. Cement products include Portland cernent, masonry, pozzolan (Type IP), roof tile, and stucco.
Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand,
gravel, and other siliceous materials. These products may contain more than 0.1%c crystalline silica.
Hazards: Freshly mixed wet cement can cause eye irritation, skin and eye burns and. allergic skin reactions. Dry concrete
and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing,
grinding, cutting and/or drilling may contain crystalline silica, which may cause silicosis and cancer if inhaled.
Health risk depends on duration and level of exposure.
Safety: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate
protective clothing. Rinse hands thoroughly after handling. Avoid breathing dust. If exposed to dust above
recommended limits (see MSDS), wear suitable' VI:OSH-approved respiratory protection.
First Aid: In case of eye contact, irriniediately flush eyes with water. If dust is inhaled, rernove to fresh air. If wet cement
contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists.
CEMEX
920 Memorial City Way, Ste. 100
Houston, Texas 77024
For further information, please visit www.cemexusa.com.
V4 combiiied
03/10
Este ticket de entrega asume aquf por referencia, que el comprador ha previarnente ctunplido con la solicitud de credito, de existir,
los terminos y condiciones estandar del vendedor, el presupuesto del vendedor, si es que existe, y con la confirmaci6n del pedido
del vendedor (incluyendo litaritaciones de garantfas), como se establece por cornpleto en este ticket de entrega ("el Acuerdo'')..E.l
vendedor suministrard los terrninos y condiciones estandar de asi solicitarrse. I:;l comprador esta de acuerdo en clue salvo que se
especifique al frente del presente, today las cantidades y artfeulos han sido e.nt:regados comp se indica, y ademds se acuerda
expresamente abonar confor•me al acuerdo.
A I S / CEMENT / PRODUCTOS DE CONCRETO
Los productos dridos son materiales de ocu.rrencia natural clue incluyen caliza, dolornita, granito, .roca volednica, arena, Brava,
y otros materiales siliceous. Los productos de ccinerrto incluyen cemento p6rtlarrd, niamposteria, puzolana, ('Tipo IP), teja y
estuco. Los productos de concreto incluyen cemento p6rtland y productos aridos inc.luyendo calza, dolornita, grar7ito, roca
volcanica, arena, Brava y otros materiales vinculados a la siliceoLIS..Estos productos podrian contener mas del 0.1% de silice
cristalina.
Peligros: El cemento fresco hirmedo mezclado puede provocar irritaci6n en .lets ojos, quemaduras de piel y Ojos, asi comp
reacciones alergicas en la piel. El, concreto seco y el polvo de rnater.iales aridos podrian provocar initaci6n en
los Ojos, piel y/o tracto respiratorio. El polvo, del manejo, triturado, molido, cortado y/o perforado podria
contener silice cristalina, que podria causar silicosis'.y dancer de ser inhalada. Los riesgos a la salud dependen
de la duraci6n y del nivel de la exposici6n.
Seguridad: Evite el contacto con los ojos y el. contacto prolongado con la pi.el. Use guantes, proteccion ocular y ropa
protectora apropiada. Enjuiguese Bien las rnanos luego del inanipulado: Evite respirar polvo. Si se expone al
polvo por encima de los limites recornendad.os anteriormente (vease MSDS por su sigla en ingles), use la
apropiada protecti6n respiratoria aprobada por NIOSH.
Primeros auxilios: En caso' de contacto c6n los ojos, irimediatameiite. erijuagueselos con agua. 'Si se ha inhalado polvo,
col6quese al a.ire libre. Si el cemento humcdo entra en contacto con la piel, enjuaguela con abund.ante agua.
Obtenga la atenci6n inedica apropiada si la irritaci6n persiste.
CEMEX
920 Memorial City Way, Ste. 100
Houston, Texas 77024
V4 combinado Para mayor informacion, por favor visite www.cemexusa.com.
03/l0
zzccmc-x.
// 0 � - r-10 9x
Plant:
Begin Loading:
To Job:
Arrive Job:
Start Unload:
Finish Unload:
Leave Job:
Return Plant:
Customer Code: Customer Name: Customer Job Number: Order Code I Date:
Project Code: Project Name: Project P.O. Number: Order P.O. Number.,
Ticket Date: Delivery Address: YUCCAMap Page: Map/Row/Column:
�17Z F 7
F1'
Delivery Instructions: Dispatcher:
F Q E, C T, GNiwi 1 1 i
Ticket Number:
Due On Job:
Slump:
Truck Number:
Driver Number:
Driver Name:
End Use:
i 13 e2 0 J:
reekly ANTONUCCI
'T
Ut _GNED
1 A [3
LOAD
QUANTITY
CUMULATIVE
QUANTITY
ORDERED,
QUANTITY
MATERIAL CODE
I
PRODUCTION DESCRIPTION
UOM UNIT PRICE
AMOUNT
1 7
5 i.3 -1 C,
0 0
R1 E G
N '3 00
.77
6
-3
r 11-
-U R;
7, 14 A R 6 E
05
11.
ri �,-i 121"1 PH, 17 : 14' 41-
AL-,- TAX
--f"L nAGU11T -11TI""'
cash Check # Auth Code: Signature of Driver Receiving Cash: Cash Received: Total COD Order Amount to Collect
Check- Without Standby Charges:
Charge
Comments:
WATER ADDED: GAL YARDS INDRUM:
WHEN ADDED.
RECEIVED SIGNATURE
CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST:
FEB0 7 2011 SIGNATURE
T
Public Works Ll LOAD WAS TES �,ED�' BY:
..nip
--�Ihnm caterials where the customer designates, but the SPECIAL TERMS: AnAwatej/added is at customers own risk. if water is added on job, concrete strength
Notice: Our drivers will make ever�effort T
Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guarain WARNING: Product may cause skin and/or eye -irritation. CAUTION: Material
terms of sale and delivery and accepts concrete as Is. Due to important factors which are out of our may be hazardo 'io your afej�-and health. Please refer to.!De-backside of this ticket for important
control after delivery, this Company will not accept any responsibility for the finished results. No credit for safety handling ormationr-6n—d 'to the material safety data sheefi§ for additional information.
returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us in writing AUTHORIZ IG '.6RE: within one business day after the receipt of materials.
LOAD NMI: ;2
�IIVERSAL FIE%) T RRK1 .- 0o;,--,�.-).3.(! INVOICE
/livery Ticket incorporates herein 1., reference Buyer's previously executed r` '.it Application, if Any, Sailer's Standard
/and Conditions, Seller's Quotatio any, and Seller's Order Confirmation (in ing limitations of warranties), as if fully
orth on this Delivery Ticket. ("Agreement"). Seller will provide the Standard Terms and Conditions upon rc"Ljuest. 13uyer agrees
unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees
to pay in accgrdance with the Agreement.
AGGREGATE / CEMENT / CONCRETE PRODUCTS
Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and
other siliceous materials. Cement products include Portland cement, masonry, pozzolan ('Type IP), roof tile, and stucco.
Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand,
gravel, and other siliceous materials. These products may contain more than 0.1% crystalline silica.
Hazards: Freshly mixed wet cement can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete
and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing,
grinding, cutting and/or drilling may contain crystalline silica, which may cause silicosis and cancer if inhaled.
Health risk depends on duration and level of exposure.
Safetv: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate
protective clothing. Rinse hands thoroughly after handling. Avoid breathing dust. If exposed to dust above
recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection.
First Aid: In case of eye contract, immediately flush eyes with water. If dust. is inhaled, remove to fresh air. If wet cement
contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists.
CEMEX
920 Memorial City Way, Ste. 100
Houston, Texas 77024
For further information, please visit www.cemexusa.coni.
V4 combined
03/1.0
Este ticket de entrega asume aquf por referencia., que el comprador ha previamente cumplido con la solicitud de credito, de existir,
los terminos y condiciones estandar del vendedor, el presupuesto del vendedor, si es que existe, y con la confirmation del pedido
del vendedor (incluyendo limitaciones de garantfas), como se establece por completo en este ticket de entrega ("el Acuerdo"). El
vendedor suministrara los terminos y condiciones estdndar de asf solicitarse. El comprador estd de acuerdo en que salvo que se
especifique al frente del presente, todas las cantidades y artfculos ban lido entregados como se indica, y ademas se acuerda
expresamente abonar conforme al acuerdo.
ARIDOS / CEMENTO / PRODUCTOS DE CONCRiE TO
Los productos aridos son materiales de ocurrencia natural que incluyen caliza, dolomita, granito, roca volcanica, arena, grava,
y otros materiales siliceous. Los productos de cemento incluyen cemento portland, mamposterfa, puzolana. (Tipo 1P), teja y
estuco. Los productos de concreto incluyen cemento portland y productos aridos incluyendo caliza, dolomita, granito, roca
volcanica, arena, grava y otros materiales vinculados a la siliceous. Estos productos podrian contener mas del 0.1 % de silice
cristalina.
Peligros: El. cemento fresco humedo mezelado puede provocar irritacion en los ojos, quemaduras de piel y ojos, asi como
reacciones alergicas en la piel. El concreto seco y el polvo de materiales aridos podrfan provocar irritacion en
los ojos, piel y/o tracto respiratorio. El polvo del manejo, triturado, molido, cortado y/o perforado podrfa
contener sflice cristalina, que podrfa causar silicosis y cancer de ser inhalada. Los riesgos a la salad dependen
de la duration y del n.ivel de la exposition.
Seguridad: Evite el contacto con los ojos y el contacto prolongado con la pie]. Use guantes, proteccion ocular y ropa
protectora apropiada. Enjuaguese bien las manos luego del manipulado. Evite respirar polvo. Si se expone al
polvo por encima de los lfmites recomendados anteriormente (vease MSDS_por su sigca en ingles), use la
apropiada proteccion respiratoria apropada por NIOSH.
Primeros auxilios: En caso de contacto con los ojos, inmediatamente enjudgueselos con aqua. Si se ha inhalado polvo,
coloquese al aire libre. Si el cemento humedo entry en contacto con la piel, enluaguela con abundante agua.
Obtenga la atencion medica apropiada si ]a irritacion persiste.
CEMEX
920 Memorial City Way, Ste. 100
Houston. Texas 77024
V4 combinado
Para mayor information, por favor visite www.cemexusa.com.
03110