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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: _
Y d
•
M 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:
i
PR0005E2ROUEMEN'T LOCAT40N::
Address: /0a e_)5't 11qr 6Q& Ave—
Legal Description:
Property Tax ID#: S Gaya —(900 "" 2- Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
E�'AII.ED DE�SCRI'PTIO' ' OF W0 �K�
i
CCJNSTR TI 'N
AMM 10,N:
Additional work to be performed under t is—permit—check all that appy:
_Mechanical _Gas Tank _Gas Piping _Shutters I Windows/Doors
Electric _Plumbing _Sprinklers _Generator _;Roof Pitch
Total Sq. Ft of Construction: Sq. Ft.of First Floor:
Cost of Construction:$ Utilities: —Sewer Septic ' Building Height:
ONE NER/LEN-SE: CO R 'Cl"01
Name rryiat —1—ohfor, f Name:
Address: 10-az- Company: 44 i
City: P, S.L. State: Ft
Zip Code: 3So2 Fax: City: S• L- State:
Phone No. Zip Code: Fax:
E-Mail: & E2 _ :�J�•/ Phone No
Fill in fee simple Title Holder on next page (if different E-Maile,nn 4 ivi S dL - QOV'r7
from the Owner listed above) State or County'License CC /,ScZ 10/Z
if value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
,I
SMP'PLEMENTAL CONSl"RUCION LEEN LAW INF®RIVIATI®N.
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,)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 nd posted on the jobsite
before the first inspection. If you intend to obtain financing, onsult with lend e r an attorney before
com encin rk of recording our Notice of Commencem t.
Signature of Owner/Lessee/Contractor as A ent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF 'COUNTY OF �o
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this day of 47402.� , 20 n by this day of Jew ,203 by
��►_.5�1 ��tr,c�oon�i ��[z.�.� � tr�cr•�,�,�r J
(Name of person acknowledging) (Name of person acknowledging)
4ignaituZreof"Notaryblic-Stat f Florida) (Signature of Notary Public-S ate Florida)
Personally Known OR Produced Identification�1 Personally Known OR Produced Identification
Type of Identification Type of Identification
3kd u Produced
a..,s• 1-�a•tea•3��:p -��.�...
`' R a (Seal)LASHAHNA INGRAM
ommission No. (Seal) Commission No. qiP
-2gn���•. Notary Public-State of FI ri
MY Comm.Expires Dec 20
2 B
„PaY h —��'A I „ ;"-F >; mmission # FF 1772 9
REVIEWS FRONT Z e`b`f1RFo I A I fvS EGETATION SEA T.URTLE9ond dMA9�GR r Olar As i.
2COUNTER REV' � .Expi aq/ida REVIEW REVIEW REVIEW" "T �3
Pr 9n
DATE �';Fof F� oon—
mmission#FF 177249 i!
'"""" Bonded throw9h N
RECEIVED -: Ronal Notary 3
DATE
COMPLETED
�_ev__. 7/2014