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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED nn'
Date: Permit Num0°ber: Ii� ) -
31 R
ow 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
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PERMIT APPLICATION FOR:
PR0 ®SED INPR'®UEMENT LOCATI'®N:
Address: d
Legal Description:
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Property Tax ID Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
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DfT LED D'E�SC� IPTION OF WORK:
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C®NSTRU TION INIFOR+MATION:
ACIChtional work to be performed under this permit—c ec a tat appy:
_Mechanical _Gas Tank _Gas Piping _Shutters Windows/Doors
_Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft.of First Floor:
!
Cost of Construction:$ ® c Utilities: —Sewer —Septic Building Height:
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®W'N�ER/LE�S�SE C�.NTRACTOR.
Name A Name:
Address: Company:
City: Stater. . Address: I
Zip Code:q& Fax: City: State:
Phone No. .;Z ^Z/ �—�n Zip Code: Fax:
E-Mail: am Phone No
Fill in fee simple Title Holder on next page (if different E-Mail
from the Owner listed above) State or County License .
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required. ii
PS-W,IIP@E,M7,'iEN']Tf.A"-II"COMNSE.11 RAWS I INFORMATION':
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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 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 your Notice of Commencement.
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Signature -,f e '/Contra_�or
ssee c as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF zz�'Lt kk-,2
COUNTY OF
The forgoing instr t was acknowledged before me The forgoing instrument was acknowledged before me
this q_ day of
(:s 20Aa by this_day of 20 by
(Name ofloers7on acknowledging) (Name of person acknowledging)
7signature of Notary Public- tate of Florida (Signature of Notary Public-State of Florida
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced
Commission No. (Seal) Commission No. (Seal)
LASHAHNAINGRAM'
MY COI Im
REVIEWS FRONTfi Mille
'SUPERStgq,, � RLANS VEGETATION SEA TURTLE MANGROVE
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COUNTER
'# REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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