Loading...
HomeMy WebLinkAboutOwner Bld Aff & Util Receipt All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED L� Date: '��oIto Permit Number: illlikR-51=21"T RECEP. Building Permit Application Planning and Development Services Building and Code Regulation Division 2300 Virginia Avenue, Fort Pierce FL 34982 Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential PERMIT APPLICATION FOR: Pq!; {065EI INPR01lENtE[NF, ION: ` y n Address Legal Description"'EtYK42UCL C.l `f' Rr7 Property Tax ID#: UQ.- -]03 06 15 - C966--D Lot No. a0 Site Plan Name: Block No. g Project Name: Setbacks `Front Back: Right Side: Left Side: 77 DE1 )I.ED �EJIIPT/C�IM x is�Oi\r F ai. r S r ccusrRu '�TlnrOt11/1A1"IC)N Acicl itiona wor to ape orme under this permit cneCK a 11 that appy. _Mechanical _Gas Tank _Gas Piping _Shutters _Windows/Doors _Electric _Plumbing _Sprinklers _Generator Roof Total Sq. Ft of Construction: Sq. Ft.of First Floor: Cost of Construction:$ Utilities: —Sewer _Septic Building Height: Z.: a Name © Name: Address: �,��{,�PQ, -�- Company: City: State: Address: Zip Code: --�LIU k a Fax: City: State: Phone No. 771 t 17 - [G'1[,7 Zip Code: Fax: E-Mail: '.12,t2.C-C7 Phone No Fill in fee simple Title Holder on next page (if different E-Mail from the Owner listed above) State or County License If value of construction is 2500 or more,a RECORDED Notice of Commencement is required. � . oMAL C( S Rel TIC}N Ll NLA l� RN1AT� l .. H DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: _Not Applicable Name: Name: Address: Address: City: State: City: State: Zip: Phone Zip: Phone: FEE SIMPLE TITLE HOLDER: _Not Applicable BONDING COMPANY: _Not Applicable Name: Name: Address: Address: City: City: Zip: Phone: Zip: Phone: OWNER/CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated. I certify that no work or installation has commenced prior to the issuance of a permit. St.Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such structure.Please consult with your Home Owners Association and review your deed for any restrictions which may apply. In consideration of the granting of this requested permit, I do hereby agree that i will,in all respects,perform the work in accordance with the approved plans,the Florida Building Codes and St. Lucie County Amendments. The following building permit applications are exempt from undergoing a full concurrency review:room additions, accessory structures,swimming pools,fences,walls,signs,screen rooms and accessory uses to another non-residential use WARNING TO OWNER:Your failure to Record a Notice of Commencement may 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 lender or an attorney before commencing work or recording our Notice of Commencement. sig6ature of wner/Lessee/Contractor as Agent for Owner Signature of Contractor/License Holder /_ L STATE OF FLORIDA STATE OF FLORIDA COUNTY OF COUNTY OF The forgoing instrume t was acknowledged before me The forgoing instrument was acknowledged before me this /4( day of 20 by this day of 20_ by (Name of erson acknowledge } (Name of person acknowledging) (Signature ic-Sof Florida} (Signature of Notary Public-State of Florida } Personally DOUGW MN Identification Personally Known OR Produced Identification Type of I ARYPtK� Type of Identification Produce STATE OFa+owoIlk Produced Commission E)*ft 2/10M8 (Seal) Commission No. (Seat) REVIEWS FRONT ZONING SUPERVISOR PIANS VEGETATION SEA TURTLE MANGROVE COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW DATE RECEIVED DATE COMPLETED Rev. ECE Planning&Development Services Department ® Building&Code Regulations a • 2300 Virginia Avenue m ,-<---- --- 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 for your use and occupancy. You may also build or improve a commercial building at a cost not exceeding $75,000.00 as long as it is for your own use or occupancy. You may not build or improve said structures for the purposes of selling or leasing that building. If you sell or lease a building you have built or improved within one year after construction is complete, then a presumption is created that it was built or improved 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 icensed contractor who is not licensed to perform the work being done. Your construction must comply with all a able 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 eet 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. (I Initial I understand that if I compensate any person or company for work performed they are require4 to be licensed in this jurisdiction. If for some reason they do not possess a license,I may be responsible and liabl f 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 cal 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 day of of 20 Owner/Buil Signature STATE OF FLORIDA COUNTY OF il' • L Q,,-\� The foregoing instrument was acknowledged before me this��day of �� ,20 by �O b V\ k \ 5 who is personally known ton or w a GIVENS produced L as identification:`"' uE,Nh:• Public State o1 Flo;i;ia NotaY fres Dec 16,2016 EE 858761 Signature of Not Type or Print Name of Notary .` Gorr(rg W Assn. Title:Notary Public Commission Numbers 5d,1� ' + noe4 '.;rc'S1i Natrona)Notary SLCPDSD Revised 05/15/2014 4 wity • ::,o rt V�ie_ RECE1'. `D rce Ut i 1 i t i es 206 S 6th Street Fort Pierce, FL 34950 :lephone No. (772) 466-1600 (/13/16 3:21PM Phone(772)466-1600 ,ceipt #: 031160713000001 Fax (772)461-1938 Istomer #: 246975 )cation #: 10006973 Ir: SUZANNE COLLINS � °yment Received: 290.00 5 fount Tendered - Cash: 290.00 yment will be posted: 07-13-2016 3 PREPARED BY:WARE gister: CASHIER31 Thank you - Have a nice day.. .. 'ORT PIERCE FL USA 34982-7624 NEW HOURS M-F 9AM - 5PM DRIVE THRU 8AM - 5PM www.FPUA.com ILY U/G 1 $250.00 $250.00 ** Budget Billing Now Available #* NEW CUST $0.01 $40.00 $0.00 $0.00 CUSTOMER COPY $290.00 Customers will be assessed wastewater charges the day they connect to the wastewater system or within 365 days from date wastewater Connection Charge is paid - whichever is first. The cost of the service line from the point of delivery at the property line to the house/building is the responsibility of the customer and is not included in this invoice. State laws require that a permit from the Health Department must be obtained prior to initiating a septic tank abandonment.Contact the Health Department at (772)873-4931. Constr4dion cost estimates are based on current labor, equipment and material prices. Actual costs of construction will be determined at the completion of the project. S"Id unforeseen circumstances be encountered during construction, including but not limited to adverse weather"conditions and constructi6n conflicts, the customer will be responsible for increased costs. Additional costs incurred by the customer shall not exceed fifteen (15) percent of the total estimated construction costs shown above. Estimated costs paid by the customer that exceed the actual cost of construction will be refunded by Fort Pierce Utilities Authority.All fees are due prior to any construction. Note: This is only an estimate. A bill will be provided following acceptance of the Customer Invoice once signed and dated. Please submit accepted Custoq1n, e to Customer Service at 206 South 6th Street, Ft. Pierce, FL 34950 or call (772)466-1600 to setup an Customer SignatureDate: (� Printed Name: PAGE 1 OF 1 PRINTED ON: 07/13/2016 AT 03:16 PM