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SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION
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DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: I .L Not Applicable
Name:DAVID MOORE Name:DANIEL BECKNER
Address:10499 MULLER RD FT PIERCE FL 34945 Address: 10499 MULLER RD I
City: FT PIERCE State: City: BOYNTON BEACH I I, I State:
Zip: Phone Zip: Phone: I
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FEE SIMPLE TITLE HOLDER: _Not Applicable BONDING COMPANY: ! Not Applicable
Name: Name: I i
Address:1915 CORPORATE DR Address: I
City: City:
Zip: Phone: Zip: Phone:
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OWNER/CONTRACTOR AFFIDVIT:Application is hereby made to obtain a permit toido the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit.
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St.Lucie County makes no representation that is granting a permit will authorize theppermit 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 resultlin 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 o'r':an attorney before
cornmencing work or recording our Notice of Commencement.
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Signat6f6of Owner/Lessee Contractor as Agent for Owner Signature of Contra ctor/Licen ie'Holder
STATE OF FLORIDA STATE OF FLORIDA I
COUNTY OF COUNTY OF
The forgoing instrument was acknowledged before me The f going instru ent was acknowledg before me
this�day of 20� by this T day of G1�.AIL i ,i20 by
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Name of person making statement Name of person making statement
Personally Known "�OR Produced Identification Personally Known(' OIf"Produced Identification
Type of Identification Type of Identification
Produced Produced I N
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(Signature of Notary Public-Ytate of Florida) ( Ignat of of ry c- I of Florid W
Commission No. L��9(Serr� MARIA mission No. (Seal) o�c .
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* * MYCOMMISSI IGG:30 W V w
N„ EXPIRES: ber 19,2020
p pyo BondeciTlw gKNotaySendeee
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MAN •,
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW RE
DATE
RECEIVED
DATE
COMPLETED
Rev.8/2/17 I
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