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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED !.r
Date: Permit Number:'!'
umber' ' 1 °°G/1
IRA
RECEIVED
Building Permit Application
Planning and Development Services , FFA ®9 2017
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
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PERMIT APPLICATION FOR:
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Legal Description: �.
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Property Tax ID#: 3414 J`lO- d Jd.,"0oal Lot No.
Site Plan Name: Block No.
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Project Name:
Setbacks Front Back: Right Side: Left Side:
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RUCTIC �)NFOT}�ONt �r” ;s6� 1�,; � yµ� n r
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it onal work to be pertormed under this permit—check all 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:
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Name l - Name: 04f 0
Address: 2-/ a. "X 01i Company:
City: A1Q4( State:A).t Address:1C1e ,9'0
Zip Code: 0 Fax: City: �S_ State: l
Phone No. /7 6 /` - Zip Code: .2 KS`s ;i` Fax:
E-Mail: Phone No (072) 3 f-Z---c 9C3
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed-above) State or/county License
LIf value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
5 PL' EaMIECONSTUCTI'ON N 1.A 1OR(tilll�►T� N�
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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 thepermit 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.
Signature of Owner/Lessee/Con rac or as Agent for Owner Signature o ontrac or/License Holder
STATE OF FLORID�aJ2' 0�� STATE OF FLORIDA
COUNTY OF �JI COUNTY OF
The forgoing instru t was acknowledged before me The forgoing i"nsti u was acknowledged before me
this day of 2049 by this L_day of 20_ by
(Name of person acknowl ing) (Name of per on cknowledging)
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(Signature of Notary Public-State of Florida ) (Signature of Notary Public-State of Florida)
a•""��•,, JOSE FRESNILLO Mk ,,,Lc
Personally Known P oIG�titP�r Fi�rida _Personally Known. �. 4ed Iden� ar'�NILLO
Type of Identification ,• •_ Commission#FF 184850 YP. =iNotar Public-State of Florida
tr 3 = a of Identification - Y=• Commission#FF 184850
Produced. =;� "a:= IN Comm.Expires Dec 22,2018 Produced x 3NPr
Bonded through National Notary Assn. -.,�FOFFyr"'• Comm.Expires Dec 22,2018
�� BondG�,thro h National Notary Assn.
Commission No. (Sa'i)". Commission No. —ter a
REVIEWS FRONT ZONING SUPERVISOR PLANS . VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 4