HomeMy WebLinkAboutOwner Builder AffidavitAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: / Permit Number.
RECEMD
•
Building Permit Application FEB 1 3 1018
Planning and Development Services Permitting Department
Building and Code Regulation Division St. Lucie County
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
PERMIT APPLICATION FOR:
PROPOSED INPROVEMENT LOCATION:
Address: `�,ZCJ r%P�2,1� �/� Z`i/ A\_�
Legal Description:
Property Tax ID #: (� l� I %2 l '�T iO? Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION OF WORK:
-- __ - _-- - - --------- ---
�—►'zi
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit -check all that appy:
_Mechanical _ Gas Tank _ Gas Piping _ Shutters _ Windows/Doors
_ Electric _ Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total5q-ft-ofConstruction:y-�y�,�� t-- Sq. Ft. of First Floor:
Cost of Construction: $ z,Jc�IJ�Utilities: —Sewer —Septic Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name &
Name:
Address: ) 0e'e� JJH'_' A-b6�'
Company:
Address:
City: Y,rP� State:
City: State:
Zip Code: 3�1 Fax:
Phone No. 386 405 S_5SE_5
Zip Code: Fax:
E-Mail:1/�-i0 Cg-p l
Phone No
Fill in fee simple Title Holder on next page ( if different
E-Mail
State or County License
from the Owner listed above)
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
Address:
City: State:
City: State:
Zip: Phone
Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
BONDING COMPANY: Not Applicable
Name:
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.
Rev. 7/2014
Signature of OvInr Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA
COUNTY OF 54 L0 C'
COUNTY OF
The forgoing instrument was acknowledged before me
The forgoing instrument was acknowledged before me
this t'� day of F-r_VJ 20_0 by
this day of 20_ by
! I I (9 nIn1S� (,1�
J)
(Name of pe s n acknowledgin
(Name of person acknowledging )
(Signature of Notary Public- State of Florida)
(Signature of Notary Public- State of Florida )
Personally Known OR Produced Identification
Personally Known OR Produced Identification
,.....�� J
Type of Identifica=QP;'
Type of Identification
ProducedNA MARIE GIVENS
Produced
MY COMMISSION # GG 02202.1Commission
No.FacPREs:�r10202J +
nded Thr,, P! ry blic Unden+mlels
Commission No. (Seal)
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEATURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 7/2014