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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTEDI
Date: Permit Number: N .0019
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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:
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PROPOSED
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.Address: �� �' 12C�aeelq 1
Legal Description:
Property Tax ID#: r��� a0 ��� Lot No.
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Site Plan Name: I Block No.
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Project Name:
Setbacks Front Back: Right Side: Left Side.,
DAII:ED DESCRIPTLON OF WORK
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°�CO�NS�TRUC,�TIO�N�LNF�ORM'ATION
Additional work to be pertormed under this permit—check all that appy:
_Mechanical _Gas Tank _Gas Piping _Shuttersf/ Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft.of First Floor:
Cost of Construction: $ f00W Utilities: —Sewer —Se ptiBuilding Height:
�O�VI/NER/ SE; CONTRACTOR
Name Name: L4z54 0 GG/
Address: Company:
City: ��e�t( rte Stater Address: 3 3I
Zip Code: Fax: City: �� �+ State
Phone No. C/6�' ��� _ Zip CodeFax:
E-Mail: Phone No
Fill in fee simple Title Holder on next page (if different E-Mail 11pa G=
from the Owner listed above) State or County License ���d3
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL C®N�Sl"RUCT!®N LI�EdN LAW IN,FaR�,IUTATFON'-: ,�::
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
comme.r%cing work or recording our Notice of Commencement.
Sign to a of Owner/Lessee/ tractor as Agent for Owner Signa Gre f Contract r/Licens der
STVE OF FLORID STATE OF FLORIDA
COUNTY OF COUNTY OF—
The fZing instrument was acknowledged before me The fo oing instrument was acknowledged before me
thisday of `� 20_Q by thi�A day of 20� by
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(Name of person knowledging) (Name otpersA acknowledging)
KiOatdre of Notary Public-StNe of Florida) (Signa re of Notary Public-S ate of Florida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
���RRY pUg,,
Pro uc`d Produced LASHAHNA INGRAM_
gr„ ,o Public State of Flor
��pRv'p� ildA if'a-,,?i A,� a My DOq� E�1ohES Dec 20,"I
Commission No. .��; .aa#ary Public-State afi Fommission No. :+� °or t;olbn FF 177245
's• a•_My Comm.Expires Dec'4,i:,. ``'%°�,it�� Bonded through National Notary Assn.,
omm° ; ono 1
ate iii• 8o ded throu h National N tary Assn.:%
REVIEWS FRONT R -PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
ev.