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.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER:
Name:
t/ Not Applicable MORTGAGE COMPANY:
Name:
. // Not Applicable
Address:Address:
Citv:State:Citv:State:
Zip: Phone Zio: Phone:
FEE SIMPLE TITLE HOLDER:
Name:
J Not Applicable BONDING COMPANY:
Name:
■f/Not Applicable
Address:Address:
Citv:Citv:
Zip: Phone:Zip: Phone:
OWNER/ CONTRAaOR 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. Lucle County makes no representation that is granting a permit will authorize the permit holder to build the subject structurewhich is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit suchstructure. 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. Lucle 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 Ov/ror/ Lessee/Contractor as Agent for Owner
STATE OF FLORIDACOUNTY OF if. Lud<^
The forgoing Instrument was acknowledged before me
this i?^dav of (f}c.4-dkffr 20 17 by
Name of person making statementPersonally Known i/^ OR Produced Identification
Type of Identification
Produced
(Signature of Notary Public- State of F(prraa )
. . . «r ortaaa'j CHRYSTALGOMEZCommission No. fr ^mMS5iON#FF 203322
* * EXPIRES: Februaiv 24,20t9B<-:lKct=ryS5r.ice5
Signature of ContraeWf/Ucense Holder
STATE OF FLORIDA ^
COUNTY OF LujtiJe>
The forgoing instrument vyas acknowledged before methis siik day of )or-^ 201-? by
Name of person making statement
Personally Known OR Produced Identification
Type of Identification
Produced
(Slgn'aTure of Nwary Public^-Sti^,u ^ CHRYSTAL GOMEZ
Commission No. SLO-^^Oa..
* ^ EXPIRES: Februaiy 24,201)Bonded Thro Budget Nolsry Senic s
REVIEWS FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR
REVIEW
PLANS
REVIEW
VEGETATION
REVIEW
SEA TURTLE
REVIEW
MANGROVE
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17 .