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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: 1' I �O�• " / ��o
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
12300 Virginia Avenue,Fort Pierce FL 34982
'Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
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PERMIT APPLICATION FOR:
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Address: J 991 &79 19(17®C_'
Legal Description: A (21m O `- 0o r
Property Tax ID#: 3 1 oa (.0 09'ocb?3 00 1Lot No.
Site Plan Name: ?! Block No.
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Project Name:
Setbacks Front Back: Right Side: Left Side:
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CO.NSTRUCTIiJN INF®RMATION
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Additional work to be pertormeci under this permit-check all that appy:
1 Mechanical Gas Tank Gas Piping _Shutters d� _Windows/Doors
—Electric —Plumbing _Sprinklers _Generator !_ Roof
i otal Sq. Ft of Construction: Sq. Ft. of First Floor:
1 0o
Cost of Construction: $ (0 061 Utilities: _Sewer Septic 'I Building Height:
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Name jai� A S Name: Zr V Lo t.
Address: Ot� 6r M ur-bv” Company: '.' �
City: `-"d� c C ��� State: P-L Address: n) c
Zip Code: 7 Fax: City: P..c- State:[_
Phone No. Z7 0 ZS2 Y 8 D-6 Zip Code: 3 yq�iJ? ii A Fax:
E-Mail: Phone No J- /3
Fill in fee simple Title Holder on next page(if different E-Mail qr4mbo` f
from the Owner listed above) State or County License 1' �5
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.!:
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S'RPLEI, M RA[.CONSTR7tJiCTI,®N LhEN LAUU kNPDRMA►TI®N:
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 our Notice of Commencement. -�
Signature of Owner essee/Cot ctor as Agent for Owner Signature of Contractor/Licens Holder
STATE OF FLORIDA STATE OF FLORIDA
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COUNTY OF �� r/'{/ COUNTY OF C IlaC-s
The forgoing instrume was ack 6wledged before me The for oing instrum was ackn ledged, efore me
this?,:3 day of U 20 ?by thisr�� day of -v 20 by
(Name of person ac wledging) (Name o persn ackn wledging)
(Signature of Notary Pu ' - tate of Florida) (Signature of Notab.lic-State of Florida)
Personally Known (QJi�8,rq uce Ya i �;R I te- Personally Known �N16Lp
NY P„, 0.Y PV
Type of Identification 2tP ' Type ° Sk'
o �'•• T e of Identification ,<P a'
YP 4 e"; Notary Public-State of Florida Say, a o- Notary Public State of Florida
Produced n°= mmission#FF 184850 Produced - ¢ v = ommisslon#FF 184850
My Comm.Expires Dec 22,2018' ;)syr° �e' My Comm.Expires Dec 22,201
Commission No. ��� Bondg8bmhbhNational Notary Assn. Commission No. (. gon,4&)QQghNationalNotary Assn
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