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.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
/' Not ApplicableDESIGNER/ENGINEER:
Name:
Add ress:
City:
Zip:Phon
State:
e
MORTGAGE COMPANY:
Name:
Address:
City:
Zip:Phone:
i/Not Applicable
State:
3NFEE SIMPLE TITLE HOLDER:
Name:
Ad d ress:
City:
Zip:Phone:
J Not Applicable BONDING COMPANY:
Name: ,
Address:
City:
Zip:Phone
ot Applicable
:
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 appiications 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 Jobslte
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 Owrfer/ Le^ee/Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF
The forgoing instrument was acknowledged before me
this^21^ day of_ £ , 20 by
Name of pers(^ making statement
Personally Known v OR Produced Identification
Type of Identification
Produced
(Signature of tary Public-
commission NO.
T EXP!Rt.S: February 24,2019
Be?!:;'. SLic;! Nolsry Ser.'ksS'
Signature of Contract0f?1?censd^older
STATE OF FLORIDA
COUNTY OF ^
The forgoing instrument was acknowledged before me
this day of .2017 by
Name of pers<^ making statement
Personally Known k OR Produced Identification
Type of Identification
Produced
(Signature of Ncftary Public-S' ^
CHRYSTAL GOMEZ
Commission No. fFaO^SSi.EXPlFiES: February 24,2019
Qj-.-'eJ Tnrii Budget Nolsry Ser>ices
REVIEWS FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR
REVIEW
PLANS
REVIEW
VEGETATION
REVIEW
SEA TURTLE
REVIEW
MANGROVE
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17