HomeMy WebLinkAboutScan_0002SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER:
Name:
Address: - -
Not Applicable
MORTGAGE COMPANY: X Not Applicable
Name:
Address:
City:
Zip: Phone
State:
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER:
Name:
Not Applicable
BONDING COMPANY: _KNot Applicable
Name:
Address:
City:
Zip: Phone:
Address:
City:
Zip: Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
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
STATE OF FLORIDA
COUNTY OF
COUNTY OF
The fgqojng instr mens vyas acknowledge efore me
this day of 20Tvby
The fo oing instr ment was acknowledged fore me
this day of 2�y
Name of person aking statement
Name of person �rnaking statement
i
Personally Known V OR Produced Identification
Personally Known OR Produced identification
Type of identification
Type of Identification
Produced
Produced
(Signature of Notary Public- State of Florida }
(Signature of Notary Public- State of Florida }
Com l i �,No. _., f�� p blic State of Florida (S l)
Commission No. {Seal}
A? Suzette Ritchie
y My Commission GG 135736*
p Notary Public State of Florida
Ex fres 1211212021
,. MY Commi&sitln
GG "135736
REV P
FRONT
ZONING
SUPERVISOR
P $ • GF1"6C}2f2
2SEATURTL
MANGROVE
COUNTER
REVIEW
REVIEW
REVI
REVIEW
GATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17