HomeMy WebLinkAboutBUILDING PERMIT ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
4 _ J '
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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: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT LOCATION:
Address: 121 t/6' C?fi f '. I` 12a yi
Legal Description:
Property Tax ID#: Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
[DETAILED DESCRIPTION OF WORK:
ICJ i C! r t" -v t�i, i^- •may tX L� 19°LC_ f V
CONSTRUCTION INFORMATION:
Additional work to be erformed under this permit—check all that apply:
E1HVAC Gas Tank []Gas Piping _Shutters Q Windows/Doors
1 Electric Plumbing Sprinklers 1:1 Generator U Roof Roof pitch
Total Sq. Ft of Construction: S Ft. of First Floor:
Cost of Construction:$ jam UtilitiestSewer OSeptic Building Height:
OWNERAESSEE; CONTRACTOR:
Name ,12S e Name:
Address: �o� v 'r Company; / i�f I�✓i °Z
City: GQL.m {, State: Address: s'~r�5 0;
Zip Code: 7-11`IQ Fax: City: 5'Le11-G_A— State:
Phone No. Zip Code: .�r'�- `1Y 97 Fax: 7'
E-Mail: Phone No.
Fill in fee simple Title Holder on next page( if different E-Mail: Vt'
from the Owner listed above) State or County License. C1
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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:
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, 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.
s
Si re o O r/ essee/Contractor as Agent for Owner Sigrra re of Contractor/License Holder
STATE OF FLORIDA STATE OF FLO I A
COUNTY OF a• 11 X-02 COUNTY OF Sk- _1 e
The forgoing instru ent was acknowledged before me The forgoing instrument was acknowledged before me
this day of by this 1 day of l 20 by
aason ca,r� 3ccmn n rcu-,\
of person acknowledging) (Na rson acknowledging)
(Signat re f Notary PZblic-15tate of Florida} ( ' natur of N tary Public-St to of Florida)
p� �{ CORN PersonallyKnown OR Produced Identification
Personally Known �` , '`�cTTo�ar�y Pu�trliic-state of Florida Type of Identific d
Type of Identification Pr c# f :
My m Ex eras 0 CHAD WINTERCflRN
Commission No. %;oc��o?:�' G Mar ti3,2021 Commission No $a4' Notary Public( �of Florida
Bond i igh Natianai 1lfalary Assn = Commission M GG 062220
�et�`� �BOfidlC tgroupli Natoanai Mato Also.
Revised 07/15/2014
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
COMPLETE
INITIALS
BUILDING &CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982
• 772-462-1553
FAX 772-462-1578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
Permit #
Credit Card Users: 1.50/n Surcharge added per transaction.
Payments must be received in this department by 4:00 PM for transaction to be
processed that day, if not it will be processed the following business day.
VISA MASTERCARD
Credit Card Number ql-,f'`� �' �' v :2 1
Expiration Date > Zip Code 3 �54'
3 digit security code 's
Amount $ ,2,�C) + 1.5% surcharge
Business Name: -5r_;c) i rA P14 In bray
Authorised Signatures-
Print Name:
Phone: (11 } 7
Fax: (27-7 } _2 J� 7
Comments:
SLCPDSD Revised 4101/2010 EN