HomeMy WebLinkAboutScan_0002 SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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 recordiRgyour Notice of Commencement.
Signature of Owner/Lessee/Contractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA �, 6_C 0� STATE OF FLORIDA
COUNTY OF al COUNTY OF (a eve-,
The fo oing inst um t w s acknowledged before me The forgoing instrum t was acknowledged before me
this day of11 20� by this day of 20 by
Name of pers making statement Vame o perso making statement
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced
1 C011-1 �.
(Signature of Notary Public-State of Florida) (Signature of Notary Public-State of Florida)
Comi iFsSion No
Comm' Se ])
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My COMMISSION#FF661868 *= MY CQMMISSION# F
of EXPIRES Dece tier 12,2017 �" n� EaXPIfRES D camber 12,2017
RE l jSss$os FR allota SZ(AI SIG SUPERVISOR PLANan '� �TATI �� t �#����E MANGROVE
REVIEW REVIEW RE VIE __ REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.8/2/17