HomeMy WebLinkAboutSIGNATURE PAGESUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
Address:
City: State:
Zip: Phone:
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name:
BONDING COMPANY: _Not Applicable
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 your Notice of Commencement.
Signature of Owner/ Agent/ Lessee Signature of Contractor/License
STATE OF FLORIDA STATE OF FLORIDA�L due P�
COUNTY OF � v _4!_ el COUNTY OF JT
The for inginstrur ntwAsacknowledged before me
this 7day of (/n1`9iJ , 20/ %by
(Signature of N to Publi - State'6f orida )
Personally Known V OR Produced Identification
Type of Identification Produced
Commissio�1A RONRA-HERNANDEZ
n MY�,MISSION #GG114031
EXPIRES: JUN 12, 2021
Theforgpoing instrument was acknowledged before me
this .Y day of c/ 207 by
sp"-"s r e,2l,%-
(Name of person acknowledging)
(Signature of Not ry
Personally Known Vll� OR Produced Identification
Type of Identification Produced
Commission No.
ONN40ARA-HERNANDEZ
MY COMMISSION #GG114031
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