BCP2011-04436i
c ~~ ~~ ~ Planning & Development Department
100 S. Myrtle Avenue, Suite 210
~~~e~rwater
~- ~ Clearwater, FL 33756
`' BUILDING PERMIT APPLICATION 567 Fax: (727) 562-4576
www.myc%arwate~ com
PARCEL NUMBER O~2°I / ((oRc`3 / ?S?~ / OOoO / OfoO /
PROJECT PROJECT/JOB NAME ~q~y-~)~l"~~/l~~-2iL T~~9C~~-~`W\ (~czv~,.
LOCATION PROJECT ADDRESS l J~ ~~1 ~~'?/Y~ ~F ZIP ~ ~oS
BUSINESS NAME
HONE0~3 ~~S ~Q92.
LEGAL DESCRIPTION OF PROPERTY~i~'~Ie l~ ~'~1.~
PROPERTY
OWNER
(must have
phone
number)
PROPERTY~OrWNER NAME S^CU~a1S C ~ ~~~/`-'='-
ADDRESS l 3~ ~dt(L~ D P
CITY ~ ~'~Z~^~`£~- STATE ~(_ ZIP 3 7~
PHONE $I ~ ~~ S ~~~ FAX
NAME
ARCHITECT/ ADDRESS
ENGINEER
CITY
PHONE
STATE ZIP
FAX
J
~~
I
0
Office Only
E-mail:
NAME OF COMPANY ~ `_,Frrc..rL I.1~ T (U~l~'1CJ~AQ ;"~'"`"""`~'
~
l
LIC. HOLDER ( M • ~r•
~Q/l.e'`.-f
7 • ~ 725.- fh~7
PHONEC L /
~ t -, .1`'--'~..
~
•~
CONTRACTOR
ADDRESS ~O CIS' /'C~/~ ~e ~~1'L/ TT
°` FAX 1~27~ 72Ln' Fj20 I ~t-~z - ~,
~;~ D t%',.~+';.
(please print
clearly) ~~,",~/~ ~^~,, ~
CITY ~~C.'~y ~ »`"r"~~'~ STATE ~~ ZIP 3~~~5 ~..' -Q
` N
STATE LICENSE # ~ ~C O I ~I 2Z I PCCLB # 2CrrC0 I~ZZ ~ ~'
~
,,..,.
~w N j
~ o ar
~
t
Contractor E-mail: CA~r ~ ,~l~m~ .~, n cr n L~PJ2~ Zen . ''~.Q_ ~ ~"
'
' ~"
t.~_.,
Contact for this project a-mail: Cla•/'r ~ ~ Um~n ~ tam • ~Q.fi
~~ .~~~ ifJ:
EXISTING BUILDING USE -~k-~~~
^4 PROPOSED BUILDING USE ~ ~_~~
GENERAL NUMBER OF STORIES ~ BUILDING HEIGHT NUMBER OF UNITS
PROPERTY
INFORMATION CONSTRUCTION TYPE: I II III IV V VI; P OR U
SQUARE FOOTAGE: LIVING ~d~ COMMERCIAL
ARA /CARPORT ~ OTHER TOTAL
Office Only
PLEASEFILL OUTBACKPAGE-APPL/CATIONMUSTBECOMPLETE - --- - - ----- - --
IF FAX PERMIT, PLEASE ENTER PROPERTY ADDRESS HERE:
PROJECT DESCRIPTION', I_f
~~~- spin
NATURE
OF WORK
(CHECK
ALL THAT
APPLY)
,......IBUILDING
~..._
::$MECHANICAL
~EROOFING
LANDSCAPING
TRAFFIC OPERATIONS
'ELECTRIC
:GAS
'.ENGINEERING
FUTILITIES
!CLEARING & GRUBBING
~. PLUMBING
'FIRE
(LAND RESOURCES
NEAR WETLANDS
'.OTHER
TYPE OF WORK: NEW ~ ~IADDITION REMODEL REPAIR ~3DEMOLITION BOTHER
VALUATION: $ ~~- ~~
(THIS MUST BE FILLED IN, PLEASE PRINT CLEARLY)
BOARD REVIEW REQUIRED: [ DRC DATE: CASE (circle one): FL OR FLS #
,CDB DATE: PPROVED 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 RECORbING 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.
Signature of License Holder ORAutho~zed Personnel
Date
P/ease Print Name Here /Title in Firm or Homeowner
,~
ar4
+` `~ ~~ CITY OF CLEARWATER
K c
~''' D~velop~~lent & Neighborhood Services
, T
r ~ ~ ~ " °, ~ ~ ~ "' ` . 100 SOUTH MYRTLE AVENUE
f"~~ ~ ( ~ CLEARWATER, FL 33756
%~ '~ APR 2 ~ Za ,~'(-tQNE (727) 562-4567 FAX (727) 562-4576
~:~ +-
N ~ bE~ WNER/BUILDER
Owner/Builder o a E pt from the regulations as set forth in Florida Statute 489 when building
for their own use an 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, ire ,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 ff I hire sub-contractors under a contract price, they must be
licensed to work in the City of Clearwater, g, 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 Owner/Builder contractor, and will personally supervise all work on such single-family
dwelling located at 9 ~Z i`t~21 h~ fir,
I hereby acknowledge I have read and understood the above affidavit on this d~day of A.D.,o~
~`~~~~~~3~,~~~ D
Signature
STATE OF FLORIDA
COUNTY OF PINELLAS
Be re me the undersigned, an officer duly commissioned by the
L- , ~u.L~, personally appeared
duly sworn deposes and says that he/she fully understands the c
of
of Florid n t ' 7 ~ day of
vit o avina been first
My Commission Expires:
bf the
~ ,~ Notary Public
1430-0028 REV. 8-2004