HomeMy WebLinkAboutPage 2 Application SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable MORTGAGE COMPANY: Not Applicable
Name: 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: Ity: i
Zip: Phone: Zip: Phone:
OWNER/CONTRACTOR AFFIDVIT: Application is hereby made to obtain,a permit to do the work and installation as ind'adied
I certify that no work w installation has commenced prior to the issuance of a permit.
St Lurie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which a 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 du 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 prsals,fences,walls,signs, screen roams 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 our Notice of Contrite nceme
Signatu of net/Lessee/contractor for Owner Signat a ontractor/License Holde 1
STAT FLORIDA ( 1 / STATE OF FLORI A
COUNTY OF ) 7 LIJGG �- COUNTY OF e 1.UC! If I{
v I
The f or g rostrum t s acit I dg fore me The oin mstr e t was acknowledge�ort me 1
thrsay of_ ,20by this y of 011_ 6y
Name of person m Ong statement Name at person making statement
Personally Known_,, R Produced Identification- Personally Known ✓OR Produced Identification
Type of Identification Type of Identification
Produced Produced
l
(Signature of to Public- fate of Florida ) (Signature of Nota- Pub c-State of Florida I
Commission No Commission N
; .,. .r -% SHELLYA.BARRETT _ rtr SHELLVABMRETf i
A" _ MY COMMISSIONrFF aik5 " f': MY CdAIASSICnrFF L3aCF5
EXPIREfr.April 23,26!8 ' EXPIRES: n123.2C18
.'RL WUry _
REVIEWS FRCIN I ZONING PLANS VE GROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17 --- -