HomeMy WebLinkAboutFilled Land Affidavit PLANNING &DEVELOPMENT SERVICES DEPARTMENT
Building&Code Regulations Division
- 2300 VIRGINIA AVENUE
FORT PIERCE,FL 34982-5652
(772)462-1553
FILLED LAND AFFIDAVIT
I,the undersigned, am the owner of the following described property,
3,70 Smit// /9 VC
(Parcel Id#/Legal description/
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
7.04.01(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(Please Print)
Property Owner Signature Date
STATE OF FLORIDA,COUNTY O J
ACKNO yjJJ E��DG��EyyD BEFO )MlE THIS- DAY OF 120/
Bylur7Vu �Y u� ��1 VWHO IS PERSONA LY KNOWN TOME(�)OR WHO HAS
PRODUCED 1n AS IDENTIFICATION.
SIGNATURE 01`7TY P IC YPE OR PRINT NOTAr
COMMISSION NUMBER
(SEAL)
SLCPDSD Revised 04/11/2011
AUDREYB.HUMPHREY
MY COMMISSION#FF 174772
ro? EXPIRES:March 6,2019
' ;pF•1°�'• Bonded Thru Notary Public Underwriters
"The On Time Concrete Company"O
4 CENTRAL CONCRETE SUPERMIX, INC.
-l1 CONCRETE DISPATCHERS: 1 , J�1��lf�A{� LI-J, a
South Dispatch: (305)264-7101
North Dispatch: ,(561)826-9364 CUSTOMER NO. DELIVERY TICKET DATE
Block Dispatch: (305)805-3226
�r WWW.SUPERMIX.COM
r' MAIN OFFICE: 4300 S.W. 74th Ave. • Miami, FL 33155
PHONE: (305) 262-3250 • FAX: (305) 267-0698
SERVING MIAMI-DADE, BROWARD, PALM BEACH, MARTIN & ST. LUCIE COUNTIES
SOLD TO DELIVERY ADDRESS
QUANTITY ITEM'. DESCRIPTION UNIT PRICE EXTENSION
f
MINUTES: ALLOWABLE TIME' PER MINUTE
EXTRA UNLOADING TIME CHARGE y = X$1.00 =
i
*6 MINUTES PER CU. YD. ALLOWED SHORT LOAD CHARGE y
SLUMP AMOUNT
THIS DELIVERY TOTAL ` '`'' CU. YDS.
OF YOUR ORDER FOR "' CU. YDS. TAX
CUSTOMER OR HIS AGENT ASSUMES FULL RESPONSIBILITY FOR STRENGTH AND/OR
PERFORMANCE OF ANY CONCRETE PLACED ABOVE DESIGN SLUMP OR WHEN • ®.
WATER IS ADDED. WATER ADDED a,YES ❑ NO "'.7- GLS.
TIME ARRIVED ON JOB STARTED UNLOADING FINISHED UNLOADING LEAVING THIS JOB TOTAL TIME
SUBJECT TO THE TERMS, CONDITIONS AND `CAUTION"WARNING LISTED ON BOTH THE
FRONT AND BACK OF THIS TICKET.
TRUCK DRIVER :I acknowledge that I have received and accepted the materials listed on this ticket. I
ur;derstand and agree to the terms on both the front and back of this ticket.
I ), .s•;i, ! :• z,{ .i. .k+i, L' t r.:_:;. RECEIVED BY: X
CONTROL 21 LOADING POINTS AT 16 LOCATIONS TO SERVE YOU BETTER ';i�lo,. i ;; c6;> ?a-iii e; ;
b' v, f l
0.�oacnx�4 MIAMI•DOWNTOWN MIAMI•WEST MIAMI•AIRPORT•OPA-LOCKA•MEDLEY•PERRINE•PEMBROKE P'I'NES'-'
� ti �' DEERFIELD•BOCA BATON•RIVIERA BEACH•STUART•W.BROWARD•FT.PIERCE•E.BROWARD•DELRAY
— t='"''' ' '' PRODUCERS� AND SUPPLIERS OF QUALITY READY MIXED CONCRETE AND CONCRETE BLOCK NRMC_A
DELIVERY COPY ®""
CAUTIONH FRESHLY (MIXED CEMENT, MORTAR, CONCRETE OR
GROUT MAY CAUSE SKIN INJURE' AVOID CONTACT WITH EYES WHERE
POSSIBLE AND WASH EXPOSED SKIN AREAS PROMPTLY WITH WATER,
IF ANY CEMENT MIXTURES GET INTO EYES, RINSE IMMEDIATELY AND
REPEATEDLY' WITH WATER AND CET PROMPT MEDICAL TREATMENT
SAWING, ,OR GRINDING OF CONCRETE MASONRY UNITS MAY RESULT
IN THE RELEASE OF DUST PARTICLES WHICH, WITHOUT THE USE OF
PROPER EYE. OR RESPIRATORY PROTECTION, COULD CAUSE EYE OR
J NOSE IRRITATION. THE MATERIAL SAFETY DATA SHEETS FOR THE
PRODUCTS SOL® BY CENTRAL CONCRETE SUPERI' IX, INC." ARE
AVA4ABLE UPON REQUEST
UNLOADING'
DRIVERS ARE PROHIBITED FROM' - ELIVERING-
CONCRETE EXCEPT UNDER THE TRUCK'S OWN POWER, AND WHERE
SITE CONDITIONS PERMITTHE SAFE ANIS PROPER OPERATION F HIS
E UIP ENT.-DRIVERS ARE NOT PERMITTED TO ADD WATER TO THE
MIX NOR TO GO BEYONDTHE C-URB LINE, EXCEPT, UPON THE
AUTHORIZATION OF THE PURCHASER/PURCHASER'S AGENTAND HIS
ACCEPTANCE OF RISK FOR ANY LOSS, OR DAMAGE.
BUYER, OR MIS AGENT, AGREES TO ASSUME RESPONSIBILITYFOR
CONCRETE,,ANLL ANY PROPERTY DAMAGE RESULTING FROM TRUCK
MAKING DELIVERY BEYOND CURB LINE. ALL. CLAIMS MUST BE MADE
AT-TIME, OF DELIVERY.
IF IT B COMES .NECESSARY-TO BRING ,ANY ACTION. TO COLLECT
.AMOUNTS DUE ON TH-IS INVOICE, PURCHASER SHALL BE"RESPONSIBLE
FOR REASONABLE ATTORNEY _,FE S AND COURT.COSTS INCURRED
BY E _ R -IIV :SECURIN COLLECTIONS. IIdITEREST-STALL Y FCCRE
AT 1 `I /2% PER MONTH ON OUTSTANDING BALANCES.