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SUPPLEMENTAL CONSTRUCTION LEEN 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: 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
commencin: work or recordin: our Notice of Commencement.
• /... � ' / ,
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Si:nature of Owner/L-ssee/Contractor as Agent for Owner 1 Signature of Contrac or/License Holder
STATE OF FLORIDA STATE OF FLORI
COUNTY OF S..1-.LAA-ct... COUNTY OF Nutit €
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this Up day of A.kA)- ,20IA. by this no day of .AA...-4,1 ,20(Yby
)4p Zit ID (A 14.bZ- kt W./iv A.wn I?...-
Name of person 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 -4 1 I.
II li Mil
,
dA.0.4/s. - ._., Ai ci.Y,--------- 1.. , . . i' ' .
(Signature of Notary Public-State of Florida) (Signature ��'�'�``"'' °"` "`
of Nota � '.. -
i `�pPYPv�� AREN S. N►ELSEN
������� ° ��� �-State of Florj'¢ �y tart' Public
Commission Nq .�`.w�ii% KAREN S.(S@13�LSEN I Commission No. ='•���•= .mmissio4�' �G� 207484
ate of Florida-Notary Public S,!t;71Irr:Y
-24-' r o„�v PAy Commission Expires •
•= Commission.# GG 207484 ' "����"� June 12, 2022
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