HomeMy WebLinkAboutZoning Compliance/Use Permit -,-, ,.w x *+ mac* r
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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
;UNTYBuilding and Code Regulations Division RECEIVED
2300 Virginia Ave
Fort Pierce,FL 34951 FEB 16 2016
772-462-1553
APPLICATION FOR ZONING COMPLIANCE—BUSINESS (Not in home)
Name of Business:
Type a d descriptZe
of usin
�P& I DIU
Number of Employees / Number Parking spaces av ilable for business
Address of Business: i FL Zip_3ft—
Name of ShoppingaCer, a plicable:
Name of ApplicantMailing Address: ,� `,, 4 02•
Contact Phone: Email:
Property Tag ID#:(Available from the Property Appraiser's Office) 62 _J12 40/1
Is this a restaurant?Yes—NO-Alf yes,will alcohol be served?Yes_NoA—Comply with distance req:Yes No/
If yes,need a copy of License from ATF
Is this a conditional Use?Yes /No If yes,please attach Conditional use document with conditions of approval.
I understand it is my responsibility to contact the Fire Department prior to the issuance of the Zoning Compliance. This
application certifies that the property on which the above described business will operate is properly zoned for that purpose
pursuao applicable county land development code regulations. I further understand that a site inspection may be
rei to ens 're compliance with applicable land development,building,sty,and property maintenance regulations.
1
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AIU:ic:a:ntls Signature Date Please Print Name
Ou
Zoning: Land Use: 119AA- SIC Code:
Landscaping Req.:Yes/No; Parking Req:Yes/No Notes:
Name.&type of previous business: Site Plan Name:
Verify if proposed use triggers a"Change in Occupancy"? Yes/No;Building permit needed:Yes/No
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PDS Staff V U Date
Revised 6/12/2015
PLANNING & DEVELOPMENT
BOARD OF 4 k SERVICES DEPARTMENT
COUNTY COUNTY
COMMISSIONERS Building & Code Regulation
Division
Occupancy Classification Affidavit
As provided in Section 310.1 of the 2010 Florida Building Code, a child or adult
care facility with 5 or fewer persons shall be classified as Group R-3.
I, the owner/ operator of the Residential Care
Living Facility Iodated at /dllf-, do affirm that I will
operate aid facility with no more than five persons of any age for less than 24
h rs. ,
W
/Operator
State of Florida
County of St. Lucie
On this.&—day of yearv2'0 (o , affirmed and subscribed before
me byDrn h Dlrec&n , who is personally know to me 1
who produced as identification �C
Notary Publi
Notary Stamp
•�.�r Pr��., AUDREY B.HUMPHREY
' F MY COMMISSION ii FF 174772
y a EXPIRES:March 6,2019
'a;FQF :?Q••• Bonded Thru Notary Public Underwriters
CHRIS DZADOVSKY,District No.1 •TOD NIOWERY,District No.2•PAULA A.LEWIS,District No.3•FRANNIE HUPCHINSON,District No.4•KIM JOHNSON,District No.5
Website:www.stlucieco.gov
2300 Virginia Avenue-Fort Pierce,FL. 34982-5652
Phone(772)462-1553 FAX(772)462-1578
A -CA,
FLOWAAGENGYFORhiEAfJHDWAWdI SUATION —.— -.-----_—
Better Health Care For All Floridians
Adult Family Care Home
Local Zoning Form
This form is to be completed by the local zoning office and not by the adult family care home(AFCH)
applicant. A copy of this form completed by the appropriate zoning official must accompany the
application.
TO: The Agency for Health Care Administration
Division of Health Quality Assurance
Bureau of Long Term Care Services
Assisted Living Unit
2727 Mahan Drive
Tallahassee,Florida 32308-
REGARDING:Name of Provider .
! `
Street Address �-/
City,State&Zip pl��'plC , El. 3 r 9d
We have reviewed the status of the above referenced AYCH and find that it is properly zoned according to
local codes. The maximum capacity ofthis AFCH isesidents.
Signature of Zoning Official
Printed Name of Official
Title
Agency Name U �
Street Address aa-o
City and Zip FV, ja e-rm�
Telephone 17Z - 4&�?-
Date:
AHCA Form 3180-1021,September 1996
2727 Mahan Drive, MS#30 �' Visit AHCA online'at
Tallahassee, Florida 32308 http://ahea.myflorida.com
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