BCP2010-10424Clearwater
PROJECT
LOCATION
Planning & Development Department
100 S. Myrtle Avenue, Suite 210
Clearwater, FL 33756
BUILDING PERMIT APPLICATION 567 Fax: (727) 562-4576
www.myc%anvatercom
PARCEL NUMBER / / / / !
PROJECT/JOB NAME
PROJECT ADDRESS 'IZS L~'t.rl~~„` JJI"7V~ ZIP ~ 37~5-
BUSINESS NAME PHONE
LEGAL DESCRIPTION OF PROPERTY
PROPERTY OWNER NAME I'(nct.v~Z~~~~.~1_ ~v~
PROPERTY _ ~~pp
OWNER ADDRESS qZS ~GU-/i/l~cz,w` D~
(must have ,9
phone CITY ~ ~C-2-a_x' ~t~~~L- STATE ~ ~ ZIP ~ 3 so
number)
PHONE ~'Z~-~-Y~~-l /`T~ FAX
NAME
ARCHITECT/ ADDRESS
ENGINEER
CITY STATE ZIP
PHONE FAX
E-mail:
CONTRACTOR
(please print
clearly)
NAME OF COMPANY ~~ , ~~---f}I~ {-fTJ-f'{I
LIC. HOLDER PHONE
ADDRESS ~ ~~ fi(~, ~ t'1G{.bv~/ ~~ FAX
CITY ~~Q,Q(~JGLI G~ (Z ~ STATE ~~ZIP
STATE LICENSE # PCCLB #
Contractor E-mail:
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Contact for this project e-mail:
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EXISTING BUILDING USE PROPOSED BUILDING USE
GENERAL NUMBER OF STORIES BUILDING HEIGHT NUMBER OF UNITS
PROPERTY CONSTRUCTION TYPE: I II III IV V VI; P OR U
INFORMATION
SQUARE FOOTAGE: LIVING COMMERCIAL
GARAGE/CARPORT OTHER TOTAL
PLEASEF/LL OUTBACKPAGE-APPL/CAT/ONMUSTBE COMPLETE
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Office Only
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Office Only
IF FAX PERMIT, PLEASE ENTER PROPERTY ADDRESS HERE:
PROJECT ESCRIPTIO
~ ~; ~ ~ ~
NATURE
OF WORK
(CHECK
ALL THAT
APPLY)
BUILDING
.MECHANICAL
PROOFING
LANDSCAPING
i~TRAFFIC OPERATIONS
~~'ELECTRIC
'~~"GAS
:ENGINEERING
:UTILITIES
:CLEARING & GRUBBING
`~"gPLUMBING
'FIRE
!LAND RESOURCES
'NEAR WETLANDS
iOTHER
TYPE OF WORK: SINEW ...ADDITIONREMODEL REPAIR ~ DEMOLITION MOTHER
VALUATION: $.
BOARD REVIEW REQUIRED: DRC DATE:
CDB DATE:
(THIS MUST BE FILLED IN, PLEASE PRINT CLEARLY)
CASE (circle one): FL OR FLS #
APPROVED DENIED
Anyone planning to do excavation work, must notify the one-call "CALL SUNSHINE" Notification Center at 1-800-432-4770 prior to any
excavation work being done, in order to prevent underground damage. Federal D.O.T. Regulation Part 192, Sections 192.614 and 192.707.
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 and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction.
CERTIFICATION:
I HAVE COMPLIED WITH ALL THE FEDERAL, STATE AND LOCAL ASBESTOS REGULATIONS CONCERNING NOTIFICATION OF THE
PROPER AUTHORITIES OF THE PROPOSED DEMOLITION AND RENOVATION PROJECTS.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY.
IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
I am aware of Florida and Federal Accessibility Codes, and I certify that I have met the requirements of both.
I certify that, this application together with any plans submitted is accurate and represents all work being done at this time. All work will be done
incompliance with all applicable laws regulating construction and zoning and if not I realize I am responsible for-the removal of any construction
in violation of these laws or regulations. Any deviation from information submitted, unless approved by the Building Official will render this
permit null and void.
IS THIS APPLICATION THE RESULT OF A STOP WORK ORDER OR NOTICE OF VIOLATION? YES_NO~
PAYMENT METHOD: CASH '=.~CHECK ~ CREDIT CARD - If paying by credit card include authorization form.
__ ~ 1 ~ ~ 2 z~ 201 D
Signature of Licen ' Ho/de /~erized Personnel Date
"~i to n1 N-I~-~I.ty 1-~~.~~.
P/ease Print Name He~+e /Title in Finn or Homeowner
°~ CITY OF CLEARWATER
~''= a Development & Neighborhood Services
= ~ 100 SOUTH MYRTLE AVENUE
~ CLEARWATER, FL 33756
PHONE (727) 562-4567 FAX (727) 562-4576
OWNER/BUILDER
Owner/Builder of asingle-family dwelling are exempt from the regulations as set forth in Florida Statute 489 when building
for their own use and occupanck
The sale or lease, or offering for sale or lease, of said structure for a period of one (1) year after construction is a criminal
violation punishable as a misdemeanor of the 2nd degree.
For your information, the OwnerBuilder becomes liable and responsible for the employees he hires to assist in the
construction project. This responsibility may include the following when required by law:
A. Worker's compensation (for workers injured on the job).
B. Social Security Tax (must be deducted from the employee's wages and matched with the owner's funds).
C. Unemployment Compensation (may or may not be required).
D. Liability Coverage
E. Federal Withholding Tax
OWNER/BUILDER AFFIDAVIT
I acknowledge that as an Owner/Builder, according to Florida Statutes Chapter 489, Part I, that I am obligated to actually,
physically, build the single-family dwelling which I have permitted.
I understand that if I am not physically doing the work or physically supervising free labor from friends or relatives, that I must
hire licensed contractors, ,jg_, master electrician, master plumbing, master HVAC (heating, ventilation, & air conditioning).
further understand the violation of not physically doing the work, and the use of unlicensed contractors at the construction
site, will cause the project to be shut down by the inspection staff of the City of Clearwater, Development & Neighborhood
Services. I also understand if this violation does occur, in order for the job to proceed, I will have a licensed contractor come
in and sign on the permit as taking the job over. I understand if I hire sub-contractors under a contract price, they must be
licensed to work in the City of Clearwater, i~ masonry, drywall, carpentry. (All contractors licensed by the Pinellas County
Construction Licensing Board have bond and liability coverage and are registered with the State of Florida).
I will assume full responsibility as a OwnerBuilder contractor, and will
dwelling located at Cj ~~~AR! HRM ~ R CL~A QI,Jf~~.k
all work on such single-family
I hereby acknowledge I have read and understood the above affidavit on this ~ day of _ ~ C~CS ~e2 20 f U A.D.,
re
STATE OF FLORIDA
COUNTY OF PINELLAS
Before a the undersigned, an officer duly commissioned by the laws of the State of Florida, on this day of
O ~ , o'bld, personally appeared ~- - ~(-LC who having been first
duly sworn deposes and says that he/she fully understands the contents of th ffidavit that he/she signed.
~~ n~~^ Notary Public State of Florida Notary Public
My Commission Expires: ~/icki Jo Morahan
Faso-oo2e
~y, c` idly Commission DD795229
"PoF nod Expires 03/04/2011
p C~C~C~ad~
OCT 2 2 2010
DEVELOPMENT 6ERVICES DLPT
CITY OF CLEA(~WATEFi
REV. &2004