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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
4710- r l
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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:
PRO @SED INPROUEMENT LOCATION:
Address: 5J r IF SAS
Legal Description:
Property Tax ID#: 43'1 JOS 004) O Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
T�Al IED DESCRIPTION CO?F WOR
=C*%N§TR4CT(ON INFORMATION:
Additional work to be pertormed unclertnis 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 Flooir:
Cost of Construction:$ Utilities: —Sewer _Septic Building Height:
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®�WNIER/aLE�S�SEE: CO,NTR �* R: r j
AC�T�O,
Name LJKI I M LSD On Zvc, Name:
Address: LC-1 /7 Company: bDNI8WNICM
" 4 !C VK,
City:. ELLE State: - Adds�s: /1�1aU rZip Code: ` Fax: City: � , �t(Cl State:
Phone No. ?21- �Ro I `A-AP Zip Code:JOU�`�2�
E-Mail: Phone No �t/- .�ou
Fill in fee simple Title Holder on next page(if different E-Mail A01 .QOM
from the Owner listed above) State or County License
if value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
.41'
SUPPLEMENTAL CONSTRUCTION LIEN LAW`tNFORMATION,
DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone: Zip: Phone:
FEE SIMPLE TITLE FOLDER: _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,l do hereby agree that 1 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 nt r as Agent for O r si a re ohContrac License Holder
STATE OF FLORID STATE OF FLORIDA J
COUNTY OF !�f Lt4 C�-P COUNTY OF ��j�. LAC C�
The forgoi g instrume t was acknowledged before me The fops g instrument was acknowledged before me
this 11ay of 20/'?—by this, day of C,-c l! 20 by
(Name of person acknowledging) (Name of person acknowledging) .•;:5 ' No•
�� <• = p�
(Signature of Notary Public State of Florid """' (Signatureo otary Public-State of Florida)
Cho Cl)
Personally Known &, OR Produced Id tIJc`Ji& Personally Known �OR Produced Identifica n3 c
Type of Identification Produced a, a '0 5 Type of Identification Produced �`�
/ p K n O / q 7 9.
Commission No. f�Q9�e�9 (S 1)= 9 70 Commission No. �D'7,�06 I (Seal) ti n
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Revised 07/15/2014 N o s
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