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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
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Date: Permit Number:
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:
Address: 5103 girckn 'srwe Fork Pi•exc� , � 34G$Z
i
Legal Description:
Property Tax ID #: 311,e&- - 0 3-4-3 -000 -'-1
Site Plan Name:
Project Name:
Setbacks Front Back: Right Side:
Left Side:
Lot No.
Block No. .
Additional work to be performed under tnis permit- cnecK all tnat apply:
_Mechanical _ Gas Tank _ Gas Piping _ Shutters _ Windows/Doors
_ Electric _ Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction:
Cost of Construction: $ 0
Sq. Ft. of First Floor:
Utilities: '_ Sewer _Septic
Name Wkso'- GAC -e'en Name: Sz\F
Address: 5103 $iccNn Company: �
City: i . Pcexcs .(l 3492,1 State: Cz Address:
Zip Code: 34q%2 Fax: City:
Phone No. -4--+z. -559 - (o�+o ck Zip Code:
E -Mail: disc -w,, (ell f Phone No
Fill in fee simple Title Holder on next page ( if different E -Mail i.
from the Owner listed above) State or County Licensi
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
Building Height:
Fax:
State:
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
commencine work or recordine vour. Notice of Commencement.
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Signature of Owner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA Q I
STATE OF FLORIDA
COUNTY OF C 't -C
COUNTY OF
Theor oing instru ent wa ckn wledgrefore me
The forgoing instrument was acknowledged before me
this day of 20 by'
this day of , 20_ -by
ti 50_". ( `-7
(Name of person acknowledging)
C ka J� 0 .4 101
(Name of person acknowledging)
(Sin tore -8 Pub'51c- State of Florida
(Signature of Notary Public -.State of Florida )
Personally Known OR Produced Identification
Personally Known OR Produced Identification
T e o icatio
Type of Identification
Produced
Produced
oo
Commission No.: ota"" P`9 -. ANGEL4 F
Commission No. (Seal)
ary Public - State of Florida
Commission
# FF 2147,2n
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