Fillable Form 20: Community Development Department (Charlotte County BCC)

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Form 20: Community Development Department (Charlotte County BCC)

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Community Development Department
Building Construction Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Permit Number:
For Office Use Only
Application date:
20
CSR Initials
ONE & TWO FAMILY RESIDENTIAL PERMIT APPLICATION CHECKLIST
***Incomplete permit applications will be returned to the applicant. Please review package contents with
this checklist to insure that all appropriate documentation is included with your submittal.***
***DO NOT STAPLE ANY OF THE BELOW DOCUMENTATION TO THE BUILDING PLANS.***
Florida Building Code 7th Edition (2020)
APPLICATION FOR CONSTRUCTION PERMIT FORM - Filled out completely with notarized signatures.
OWNER-BUILDER DISCLOSURE STATEMENT - ONLY if owner acts as contractor - An affidavit signed by the owner/
builder certifying that the responsibilities and requirements of the construction process are understood by the owner.
NOTICE OF COMMENCEMENT (NOC)- A recorded NOC will be required before scheduling first inspection.
SUBCONTRACTOR WORKSHEET - Signed by the contractor.
FIRE HYDRANT AFFIDAVIT- Signed by the owner and notarized.
SEWER/SEPTIC AFFIDAVIT - Signed by owner/agent/or contractor and notarized. Provide name of provider company.
SEPTIC SYSTEM PERMIT - (If sewer service is not available) - A copy of the septic system permit approved by the Health
Department (941.743.1266). An approved septic permit must be on file prior to the building permit being approved.
PUBLIC UTILITY AFFIDAVIT- An affidavit regarding the location of existing public utility structures on the site.
SURVEYS - Two (2) signed and sealed surveys of less than one year old which include flood zone and panel number
information.
TREE PRESERVATION/REMOVAL FORMS - Appropriate tree forms must be completed with site plan attached.
SITE PLANS - Three (3) original signed and sealed site plans showing existing improvements on the site, property lines,
setbacks for proposed project and culvert information for Right Of Way.
DRAINAGE PLANS - Two (2) drawings of site drainage plans showing proposed ground and final floor elevations.
1 & 2 FAMILY DATA SUMMARY SHEET - Two (2) showing design data and signed by structural designer. Or all the
information asked in the form to be in the building plans.
BUILDING PLANS - Two (2) sets of building plans that have been signed and sealed by an engineer or architect, if
applicable per current Florida Building Code.
PRODUCT APPROVALS - NOA or product approval number of windows, door, shutters, soffits, siding and roof covering
materials as applicable to the project.
TRUSS LAYOUTS - Two (2) sets of truss layouts or framing details reviewing and approved by structural designer.
ENERGY FORMS - Two (2) sets of energy calculations as per Energy Conservation Code.
NEW RESIDENTIAL UTILITY SERVICE APPLICATION - Form CCU-F003) Completed form will be forwarded to Charlotte
County Utilities (please provide a copy of Site Plan).
PRE-APPLICATION FEE - A pre-application fee of $150 is due at time of application submittal.
If you have any questions, please call the following:
Permitting: 941.743.1201
Zoning: 941.743.1964
Land Development (ROW): 941.743.1264
Addressing: 941.743.1235
FL Health Department: 941.743.1266
11/2020 jg
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
Community Development Department
Building Construction Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Permit Number:
For Office Use Only
Application date:
20
CSR Initials
ONE & TWO FAMILY RESIDENTIAL PERMIT APPLICATION
Florida Building Code 7th Edition (2020)
Permit application includes also: (if items are not checked but will be done, separate permit will be required)
Gas LP Tank Gas Piping
Number & Street
Type:(St., Dr., Pkwy., Blvd., etc.)
Description of work to be done
Address:
This building will be used as
Construction Cost (excluding lot but including labor):
City State Zip
Water Service Source/Company:
Zoning Class:
Heat(kw): Electrical Service (AMPS):
A/C (Tons):
Septic Permit #/Sewer Company :
Job Site Details
Owner Information
Name:
Address:
Phone No. :
Email:
Number & Street
Type:(St., Dr., Pkwy., Blvd., etc.) City State Zip
Contractor Information
Name:
Contractor's License No.:
Address:
Phone No. :
Email:
Fax No.:
Number & Street
Type:(St., Dr., Pkwy., Blvd., etc.) City State Zip Code
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction.
Owners Affidavit: I hereby certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning.
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 JOB SITE BEFORE FIRST INSPECTION.
IF YOU INTENT TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF
COMMENCEMENT.
NOTICE: In addition to the requirement of this permit, there may be additional restrictions applicable to this property that may be found in the public
records of this County, and there may be additional permits required from other governmental entities such as water management districts, state, or
federal agencies.
Under penalties of perjury I declare that I have read the foregoing document and that facts stated are true, correct and in compliance with the
applicable regulations.
F.S.92.525
Contractor/Owner Builder Signature:
(Owner's signature only if owner is acting as contractor. **An Owner-Builder Disclosure Statement will be required)
NOTICE: Permit is void if construction is not started within 180 days or does not receive an approved inspection within 180 days from date of issue. An approved
inspection will extend the permit for an additional 180 days. Starting work prior to issuance of a permit may result in a penalty fee of up to four times the permit fee.
Print Name:
Date:
11/2020 jg
Unit #:
Parcel ID:
Building #:
Demolition
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signature
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Community Development Department
Building Construction Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Permit Number:
For Office Use Only
Application date:
20
CSR Initials
OWNER-BUILDER DISCLOSURE STATEMENT
(Per Florida Statute F-S 489.103.7.b)
PLEASE READ THE STATEMENT BELOW CAREFULLY. FAILURE TO COMPLY WITH THIS STATEMENT SHALL RESULT IN
YOUR PERMIT BEING REVOKED BY THE BUILDING OFFICIAL AND MAY RESULT IN FINES UP TO $10,000.
I understand that State law requires construction to be done by licensed contractor and have applied for an owner/builder
permit under an exemption to that law. The exemption specifies that I, as the owner of the property listed, may act as my
own contractor with certain restrictions even though I do not have a license.
I understand that, as an owner-builder, I am the responsible party of record on a permit. I understand that I may protect
myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my
own name. I also understand that a contractor is required by law to be licensed in Florida and to list his or her license
numbers on permits and contracts.
I understand that I may build or improve a one-family or two-family residence or a farm outbuilding. I may also build or
improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my own use or
occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or
substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I
built or substantially improved it for sale or lease, which violates the exemption.
I understand that, as the owner-builder, I must provide direct, onsite supervision of the construction.
I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building
or residence. It is my responsibility to ensure that the persons whom I employ have the licenses required by law and by
county or municipal ordinance.
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I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the
construction and is not hiring a licensed contractor to assume responsibility.
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I understand that it is a frequent practice of unlicensed persons to have the property owner obtain an owner-builder permit
that erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner-builder, may
be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or her
employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am
willfully acting as an owner-builder and am aware of the limits of my insurance coverage for injuries to workers on my
property.
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I understand that I may not delegate the responsibility for supervising work to a licensed contractor who is not licensed to
perform the work being done. Any person working on my building who is not licensed must work under my direct
supervision and must be employed by me, which means that I must comply with laws requiring the withholding of federal
income tax and social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers'
compensation for the employee. I understand that my failure to follow these laws may subject me to serious financial risk.
I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,
the United States Small Business Administration, the Florida Department of Financial Services, and the Florida Department of
Revenue. I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or www.
myfloridalicense.com/dbpr/pro/cilb/index.html for more information about licensed contractors.
I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable
laws and requirements that govern owner-builders as well as employers. I also understand that the construction must comply
with all applicable laws, ordinances, building codes, and zoning regulations.
Initials
05/2011
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
(Page 1 of 2)
Community Development Department
Building Construction Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Permit Number:
For Office Use Only
Application date:
20
CSR Initials
Plumbing
Roofing
Solar Systems
Spa /Swimming Pools
Insulation
Carpentry
Drywall
Cement, Concrete, Masonary
Ceramic/Marble/Terrazzo
Plaster/Stucco/Spraycrete
Painting and Wallcovering
Other (Detail Below)
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who
does not have a license, the Construction Industry Licensing Board and Department of Business and
Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of a
complaint. Your only remedy against an unlicensed contractor may be in civil court. It is also important for you to
understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your
property, you may be held liable for damages. If you obtain an owner-builder permit and wish to hire a licensed
contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of the
contractor's workers' compensation coverage.
I am aware of, and consent to, an owner-builder building permit applied for in my name and understand that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Number and Street City Zipcode
I agree to notify Charlotte County Community Development, Building Division, immediately of any additions, deletions, or
changes to any of the information that I have provided on this disclosure.
OWNER-BUILDER DISCLOSURE STATEMENT
(Per Florida Statute F.S. 489.103.7.b)
10/2020 jg
A/C & Heat
Electric
Aluminum
Initials
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CHECK THOSE CONTRACTOR CATEGORIES BELOW WHICH WILL BE DONE BY THE OWNER
The undersigned applicant agrees to comply with the provisions as outlined herein and with all Federal, State, and Local codes. It is further understood that a violation of
any applicable code may result in a stop work order being issued and a cessation of all work until such violation has been remedied. The undersigned applicant for this
building permit does hereby certify that Applicant has or will, prior to the performance of any work in connection with the authorization granted under this permit,
comply with the provisions of the: Florida Workman's Compensation Act; Social Security Act; Florida Child Labor Laws; Contractor's/Employer's Liability Insurance
Requirements; and all other applicable Federal, State, and Local laws, a violation of which may invoke penalties.
Under penalties of perjury I declare that I have read the foregoing document and that facts stated are true, correct and in compliance
with the applicable regulations. F.S.92.525
NOTICE: All subcontractors must have a Charlotte County Certificate of Competency. Permit is void if construction is not started within
180 days or does not receive an approved inspection within 180 days from date of issue. An approved inspection will extend the permit
for an additional 180 days. Starting work prior to issuance of a permit may result in a penalty fee of up to four times the permit fee.
Gas Piping
Fence
Landscape Irrigation
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
(Page 2 of 2)
Owner Builder Signature:
Date:
Printed name:
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signature
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NOTICE OF COMMENCEMENT
State of Florida Permit Number: _____________________________________
County of Charlotte Tax Folio or Parcel Number: ___________________________________
The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the
following information is provided in this Notice of Commencement.
1. Description of Property (a complete legal description or parcel number; and a complete street address with city/state/zip code, if available):
2. General Description of Improvement: ___________________________________________________________________________________
3. Owner Information:
a. Name: __________________________________________________________________________________________________________
b. Address: _____________________________________________ City/State/Zip Code: ________________________________________
c. Interest in Property: ______________________________________________________________________________________________
d. Name and Address of Fee Simple Title Holder (if different from the Owner listed above): ______________________________________
_________________________________________________________________________________________________________________
4. Contractor Information:
a. Name: _________________________________________________________________ Phone Number: ___________________________
b. Address: ______________________________________________ City/State/Zip Code: _______________________________________
5. Surety Information:
a. Name: _________________________________________________________________ Phone Number: ___________________________
b. Address: ______________________________________________ City/State/Zip Code: _______________________________________
c. Bond Amount: $ __________________________________________________________________________________________________
6. Lender Information:
a. Name: __________________________________________________________ Phone Number: __________________________________
b. Address: ______________________________________________ City/State/Zip Code: _______________________________________
7. Persons within the State of Florida Designated by Owner upon whom notices or other documents may be served as provided by
Section 713.13(1)(a)7., Florida Statutes:
Name/Address/Phone Number: ________________________________________________________________________________________
8. In addition to himself/herself, Owner designates the following to receive a copy of Lienor's Notice as provided in Section 713.13(1)
(b) Florida Statutes:
Name/Address/Phone Number: ________________________________________________________________________________________
9. Expiration Date of Notice of Commencement (the expiration date is one year from the recording date unless a different date is specified here):
_____________________________________________________________________________________________________________________
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE
CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB
SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY
BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
Under penalties of perjury, I declare that I have read the foregoing and that the facts in it are true to the best of my knowledge and
belief (Section 92.525, Florida Statutes).
Signature of Owner or Lessee, or Owner's or Lessee's Authorized Printed Name
Officer/Director/Partner/Manager
Company Name and Title
State of _________________________, County of __________________________ Sworn to (or affirmed) and subscribed before me, by means of
physical presence or online notarization, this ______ day of _______________, 20 _______ by_____________________________________,
(name of person making statement)
personally known, or produced identification with type of identification ________________________________________________.
Signature of Notary Public Printed or Stamped Commissioned Name of Notary Public
12/2020 jg
Community Development Department
18400 Murdock Circle, Port Charlotte, FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingSvcs@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Application Date
Permit Number
For Office Use Only
20
CSR Initials
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
10/2020 jg
Subcontractor Worksheet
This form is to be submitted at the time of Permit Application and must be completed with all information.
Changes in subcontractors are allowed by submitting a Change in Subcontractor form.
Trade
Subcontractor Company Name
Subcontractor
Telephone No.
Subcontractor
License No.
Permit Application Number
Contractor Name
Contractor's Certification or Registration No.
A/C and Heating
Electric
Plumbing
Roofing
Unit #:
Building #:
Address:
Date
Gas
Other:
Contractor Signature:
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signature
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Community Development Department
18400 Murdock Circle, Port Charlotte, FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingSvcs@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Application Date
Permit Number
For Office Use Only
20
CSR Initials
Tax Folio # Lot
10/2020 jg
AFFIDAVIT - FIRE HYDRANTS
I, the undersigned, being the legal owner of the above described property, investigated and
determined the following:
1. Public Water Service:
2. A Fire Hydrant:
Hydrant distances are as follows:
1) Mobile Homes, Single Family, Duplexes and Triplexes - Maximum 500' from building
2) Commercial, Apartments and other high value - Maximum 300' from building
3) Heavy Industrial and Manufacturing - Maximum 300' from building
If public water is available and a fire hydrant is not within the prescribed distance as stated above,
pleasecontact the appropriate utility for a fire hydrant.
Owner's Name:
Block
Subdivision
Is Available
Is NOT Available
Is Within the Prescribed Distance
Is NOT Within the Prescribed Distance
Number & Street Name
Unit #:
Building #:
Address:
The undersigned applicant agrees to comply with the provisions as outlined herein and with all Federal, State, and Local codes. It is further understood that a violation of
any applicable code may result in a stop work order being issued and a cessation of all work until such violation has been remedied. The undersigned applicant for this
building permit does hereby certify that Applicant has or will, prior to the performance of any work in connection with the authorization granted under this permit,
comply with the provisions of the: Florida Workman's Compensation Act; Social Security Act; Florida Child Labor Laws; Contractor's/Employer's Liability Insurance
Requirements; and all other applicable Federal, State, and Local laws, a violation of which may invoke penalties.
Under penalties of perjury I declare that I have read the foregoing document and that facts stated are true, correct and in compliance
with the applicable regulations. F.S.92.525
(Owner's signature if owner is acting as contractor. **An Owner/Builder Affidavit will be required)
NOTICE: All subcontractors must have a Charlotte County Certificate of Competency. Permit is void if construction is not started within
180 days or does not receive an approved inspection within 180 days from date of issue. An approved inspection will extend the permit
for an additional 180 days. Starting work prior to issuance of a permit may result in a penalty fee of up to four times the permit fee.
Contractor/Owner Builder Signature:
Contractor License Number:
Date:
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
click to sign
signature
click to edit
Community Development Department
18400 Murdock Circle, Port Charlotte, FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingSvcs@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Application Date
Permit Number
For Office Use Only
20
CSR Initials
Parcel ID #
SEWER DISPOSAL / WATER AFFIDAVIT
701.2 Sewer required. Every building in which plumbing fixtures are installed and all premises having drainage piping shall be connected to a public
sewer, where available, or an approved private sewage disposal system in accordance with the International Private Sewage Disposal Code.
Person making affidavit:
SEWAGE DISPOSAL - Please select one of the following:
Owner Name:
Number & Street Name City Zip Code
Lot
Block
Subdivision
Contractor Name
Phone #
Fax #
License #
Owner(s)
Owner(s) Agent
Owner(s) Contractor
Public Sewer Available: I, the undersigned, have verified and confirmed that the address listed above does have Public Sewer
available. If the utility company is other than Charlotte County Utilities, please provide proof of availability in the form of a
letter from the utility company on their letterhead. The permit WILL NOT be issued without proof of availability.
Onsite Sewage Disposal System: I, the undersigned, have verified and confirmed that the address listed above will have an
approved Onsite Sewage Disposal System.
Name of Utility Company:
Charlotte Co. Health Dept. Permit Number:
Unit #:Building #:
Address:
WATER AVAILABILITY - Please select one of the following:
Name of Utility Company
Well Water
Public Water Available - I, the undersigned, have verified and confirmed that the address listed above does have Public Water
available. If the utility company is other than Charlotte County Utilities, please provide proof of availability in the form of a
letter from the utility company on their letterhead. The permit WILL NOT be issued without proof of availability.
NOTE: All multi-unit structures that will be served by CCU low pressure sewer (LPS) will have a non-tenant associated electric
meter that will not be shut off if any unit is empty. I acknowledge that I have read and understand all Charlotte County Utilities
Standard Specifications and Drawing Details related to LPS installation (CCU 941.764.4300 , Ext. 3).
10/2020 jg
The undersigned applicant agrees to comply with the provisions as outlined herein and with all Federal, State, and Local codes. It is further understood that a violation of
any applicable code may result in a stop work order being issued and a cessation of all work until such violation has been remedied. The undersigned applicant for this
building permit does hereby certify that Applicant has or will, prior to the performance of any work in connection with the authorization granted under this permit,
comply with the provisions of the: Florida Workman's Compensation Act; Social Security Act; Florida Child Labor Laws; Contractor's/Employer's Liability Insurance
Requirements; and all other applicable Federal, State, and Local laws, a violation of which may invoke penalties.
Under penalties of perjury I declare that I have read the foregoing document and that facts stated are true, correct and in compliance
with the applicable regulations. F.S.92.525
(Owner's signature if owner is acting as contractor. **An Owner/Builder Affidavit will be required)
NOTICE: All subcontractors must have a Charlotte County Certificate of Competency. Permit is void if construction is not started within
180 days or does not receive an approved inspection within 180 days from date of issue. An approved inspection will extend the permit
for an additional 180 days. Starting work prior to issuance of a permit may result in a penalty fee of up to four times the permit fee.
Contractor/Owner Builder Signature:
Contractor License Number:
Date:
click to sign
signature
click to edit
Community Development Department
18400 Murdock Circle, Port Charlotte, FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingSvcs@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Application Date
Permit Number
For Office Use Only
20
CSR Initials
PUBLIC UTILITY AFFIDAVIT
STATEMENT THAT THE BUILDING SITE CONTAINS NO COUNTY OR PUBLIC UTILITY STRUCTURES
I, the undersigned, hereby certify that I have inspected , or caused to be inspected by a qualified person
or firm, the property proposed as the building site for which I am applying for a building permit. I have
determined that the proposed site does not contain any County or Public Utility structures above, on or
under the proposed building site, whether within or without any easements, except as noted below.
I understand that should any County or Public utility structure not disclosed above be discovered on the
proposed building site, the County will not be responsible for any expenses related to moving,
abandoning or taking any other action related to any such structure, or the proposed building or
structure, on the building site.
Number & Street Name
Name of Person Making Statement
Owner(s)
Owner(s) Agent Owner(s) Contractor
Tax Folio # Lot Block
Subdivision
Unit #:
Building #:
Address:
10/2020 jg
The undersigned applicant agrees to comply with the provisions as outlined herein and with all Federal, State, and Local codes. It is further understood that a violation of
any applicable code may result in a stop work order being issued and a cessation of all work until such violation has been remedied. The undersigned applicant for this
building permit does hereby certify that Applicant has or will, prior to the performance of any work in connection with the authorization granted under this permit,
comply with the provisions of the: Florida Workman's Compensation Act; Social Security Act; Florida Child Labor Laws; Contractor's/Employer's Liability Insurance
Requirements; and all other applicable Federal, State, and Local laws, a violation of which may invoke penalties.
Under penalties of perjury I declare that I have read the foregoing document and that facts stated are true, correct and in compliance
with the applicable regulations. F.S.92.525
(Owner's signature if owner is acting as contractor. **An Owner/Builder Affidavit will be required)
NOTICE: All subcontractors must have a Charlotte County Certificate of Competency. Permit is void if construction is not started within
180 days or does not receive an approved inspection within 180 days from date of issue. An approved inspection will extend the permit
for an additional 180 days. Starting work prior to issuance of a permit may result in a penalty fee of up to four times the permit fee.
Contractor/Owner Builder Signature:
Contractor License Number:
Date:
A recorded Notice of Commencement is required in the Permitting Office prior to the first inspection.
click to sign
signature
click to edit
Community Development Department
18400 Murdock Circle, Port Charlotte, FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Zoning Phone: 941.743.1964 | Zoning Fax: 941.743.1598
BuildingSvcs@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
Application Date
Permit Number
For Office Use Only
20
CSR Initials
Components and Cladding Design Pressures:
I certify to the best of my knowledge and belief that these plans and specifications have been
designed to comply with the structural portion of the Building Code for wind, flood and gravity
loads as amended and enforced by the permitting jurisdiction.
Architect / Engineer Seal
RESIDENTIAL ONE AND TWO SINGLE FAMILY DWELLING DATA SUMMARY SHEET
Florida Building Code 7th Edition (2020)
Applicable Codes: Building, Mechanical, Plumbing, Accessibility, & Energy Codes - 7th Edition (2020) Florida
Building Code, Residential Volume. Electrical Code - NFPA 70 & NEC 2017
Method of Design per Florida Building Code (FBC) R301:
Basic Wind Speed (Vult)
mph (Figure R301.2(4)
Exposure Category Section (R301.2.1.4)
Structural Forces (Section R301.4 / 301.5 / 3601.6)
Mean roof height
ft
Nominal Design Wind Speed (Vasd)
m.p.h.
Floor Design:
Dead Load
p.s.f
p.s.f
Window and Door Wind Pressure Design Loading:
Windows Doors
Garage Doors
p.s.f
Roof Design:
Live Load
Dead Load
p.s.f
Zone 1:
Zone 2:
Zone 3:
Zone 5:Zone 4:
p.s.f
p.s.f
p.s.f
p.s.f
Protection of Openings:
Living (Sq. Ft.) Garage (Sq. Ft.) Lanai (Sq. Ft..)
Entry (Sq. Ft.)
Storage (Sq. Ft.) Other (Sq. Ft.)
TOTAL (Sq. Ft.)
Area Tabulation:
Signature: Date:
Doors:
Manufacturer's Product Approvals
Windows:
Overhead Doors:
Mitered Glass:
Shutters:
Roof Coverings:
Soffit:
ASCE 7
MAF Guide
AF & PA
AISI S230
ICC 600
Florida Building Code, 7th Ed (2020)
Other:
B
C
OWNER NAME:
PROJECT ADDRESS:
Number & Street City, State, & Zipcode
Risk Category:
I II
Flood Design Data
D
Soil Design Load-Bearing Value
Roof Slope
Designer's Name:
Live Load
p.s.f
p.s.f
p.s.f
p.s.f
Design Data:
10/2020 jg
TMS/ASCE
Final Floor Elevation
Street City Zipcode
Legal Description: The Complete Short Legal
(Only One Lot Per Form)
(Must Include 3-Letter Identifier)
******PLEASE PROVIDE A COPY OF SITE PLAN******
SERVICE AGREEMENT: Utility will provide service upon payment of these fees and charges in accordance with Utility's Uniform
Extension Policy approved by the Board of County Commissioners. The policy provides for plant allocation of 225 gallons per day
per equivalent residential connection (ERC for water service, and 190 gallons per day per ERC for sewer service, as defined in the
policy). Utility will not be obligated to provide capacity of service in excess and may required consumers to curtail use which
exceeds such allocated capacity. Where payment of connection fees has been made prior to the availability of utility service, Utility
agrees to make service available upon completion of construction and certification that lines are ready to serve. In areas where
utility service is not available and connectiion fees have ben paid, billing of the monthly Base Facility Charge(s) will begin thirty (30)
days after certification of service availability and applicant agrees to pay such charges as rendered.
Date
<<<< FOR OFFICE USE>>>>
WATER
SEWER
TOTAL
PLANT CAPACITY (A) WPLT SPLT
TRANSMISSION (A) WTRN STRN
DISTRIBUTION (A) WDST
XXXXX
COLLECTION (A)
XXXXX
SUBTOTAL CONNECTION FEES
W + S
(A)
LOW PRESSURE INSTALL (B)
XXXXX
WATER METER INSTALL (B) MIXX
XXXXX
AGRF* (See chart on pg. 2) (B) WAGF SAGF
SUBTOTAL OTHER FEES
W + S
(B)
ESCROW CREDIT: YES NO IF YES, CHECK WILL BE SENT TO PROPERTY OWNER
*PRICES IN EFFECT UNTIL AND SUBJECT TO CHANGE.
(A) PAYCODE: CFCH (CASH) CFCK (CHECK) (B) USE REGULAR PAYCODES
APPLICATION RECEIVED
NOTES:
Serv. Type: DI S L
TOTAL CONNECTION FEES: $
PAYMENT: $ DATE:
BALANCE TO FINANCE: $ MONTHS TO FINANCE (MAX):
RECEIVED BY: APPROVED BY:
PREMISE NO: CUSTOMER NO:
SCOL
New Residential Utility Service
Application
Charlotte County Utilities
Email: administrative.assistants@charlottecountyfl.gov or
Sherri.Sartino@charlottecountyfl.gov - Fax to 941.764.4319
Forms-CCU-Eng-F003
Effective Date: 03/05/13
Page 1 of 1
Name:
Property Owner:
Mailing Address:
Phone Number: Fax Number:
Email Address:
Lot:
Block:
Section:
Address of Property:
City, County, Zip Code:
Customer Signature
STNK
TOTAL W/S CONNECTION FEES
<<<< FOR OFFICE USE>>>> <<<< FOR OFFICE USE>>>>
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Form 20: Community Development Department (Charlotte County BCC)

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Completed 21 January 2021

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