HomeMy WebLinkAboutScan_0002SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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DESIGNER/ENGINEER:
Name:
Not Applicable
MORTGAGE COMPANY:
Name:
Not Applicable
Address:
STATE OF FLORIDA r, ,
COUNTY OF
Address:
City:
Zip: Phone
State:
City:
Zip: Phone:
State:
FEE SIMPLE TITLE HOLDER:
Name:
Not Applicable
BONDING COMPANY:
Name:
XNot Applicable
Address:
City:
Zip: Phone:
Type of Identification
Address:
Produced
City:
Zip: Phone:
(Signature of Notary Public- State of Florida )
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.
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Signature of Owner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
COUNTYOF
STATE OF FLORIDA r, ,
COUNTY OF
_
The for Ding instru a was acknowledged before me
this day of C.L.�� 20 by
The for Ding instru nt as acknowledged, efore me
this day of w ' 20 by
C4 0
Name of pe making statement
Name of person making statement
Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
1 L
(Signature of Notary Public- State of Florida)
(Signature of Notary Public- State of Florida )
Commis i - — Seal)
Commission No. (Seal)
1,tataN tLt,!IC St :b o
gazette 1^iwrN"" k1,35736t
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Notaoy Public State of Florida
nmm�ss,an
UP rt VIVIIk
ZONING
SUPERVISOR
My Commission GG:36�7361=;
L 1�fiTE'174 MI TU TLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17