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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED I /
Date: Permit Number:
_ Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential'
PERMIT APPLICATION FOR:
PR®POSED INR/OVEMENT LOCATIO
Address: 3'7!`t P4.Iylte'l'al'o Df�.
Legal Description:
Property Tax ID# Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAl�LED DE��CRt'PTION OF WORK:
t C_&r djrccss a 6 �-_1� a r!
.0 •
eONSTRUCTION INFORMATION:
AcOffional work to be pertormed un er t is permit—cfieckan tat app y: /
Mechanical _Gas Tank _Gas Piping _Shutters : V. Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of,Construction: Sq. Ft.of First Floor:
Cost of Construction: Utilities: _Sewer _Septic Building Height:
OWNERE: CON R CTClR;
Name_ r#1cy� (;eddes Name:
Address: .r71q Pa_IA t �{'�oo �R. Company:
City: &r-r PierCe State: FL Address:
!Zip Code: .34Q8.2- Fax: City: State:
Phone No. 77oz .2146 — 427? Zip Code: Fax:
E-Mail: Ni-�C r, Ut, Cl Phone No
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SUPOff RIE 1T L C®013117 NORi I LIE NS ILAW 1i!NR, MAKIM N.
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 orrand 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 our Notice of Commencement.
Signature of wner/Lessee/Contractor.as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF �,.�, �, COUNTY'OF
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this V day of .� 20'11 by this day of 20_ by
(Name of person cknow edging) (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
Type of Identificatio '�` `- :„ Type of Identification
,.otiia., LASHAHNA INGRAM
Produced °��R "�'' Produced
3 , *� r o ary Public-State of Florida
Commission No. s�` *P My C�mm(Se21)es Dec 20,201B Commission No. (Seal)
Commission#FF 177299
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REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE .
COUNTER REVIEW REVIEW REVIEW REVIEW -REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
ev.