HomeMy WebLinkAboutSIGNATURE PAGEkiX^
DESIGNER/ENGINEER:
_ Not Applicable MORTGAGE COMPANY: Not Applicable
Name:
Name:
Address:
Address:
City:
ZIP: Phone
State: City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER:
_ Not Applicable
BONDING COMPANY: Applicable
Name:
_Not
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 nttoo� work or installation has commenced prior to the issuance of a permit.
which is inoconflicmtawith anrepresentation
applicable' Home Owners Association' rulesauthorize
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 feview: 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 yov intend to obtain financing, consult with lender or an attorney before
as Agent for Owner I Sigrrature of
STATE OF FLORID/ r o .� STATE OF COUNTY OF ORIDI� � i n
COUNTY OF I v ( �,j aft
in
f ng instrum t was acknowledged -before me
this d Md 20by
A SYS\-e�..1�,��,n�
Name of per on making statement
Personally Known OR Produced Identification
Type of Identification
�Zh0 � L IM M
(Signature of Notary Public- State of Florida I_
Commission No.HLEE M eaJRANENA
FF902180
EXPIRES July 22.2019
REVIEWS I FRONT ONING
CO NTER I REVIEW I REVIEW SUPERVISOR
RECEIVED
Rev. 8/2/17
The f ng instru nt was acknowledged before me
this ay of 20r— f by
Name of per making statement
Personally Known OR Produced Identification
Type of Identification
Produced
(Signature ofbRA36fta�0j[� ENA
�; MY COMMISSION 0 fF902180
Commission o. SJuy r1. U
140113"" i1pMWNob, 8
Mca.can
PLANS VEGETATION SEATURTLE MANGROVE
REVIEW I REVIEW REVIEW REVIEW