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1,
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: 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 I-nder or an attorney before
comme a 'a;l: work or recordi is our Notice of Commencement.
2
S' nature of ner/Le ee/Contractor as Agent for Owner Sign re of Contractor/Lice se Holder
STATE OF FLORIDA STATE OF FLORI A
COUNTY OF $ � /. Cr L u p COUNTY OF 5 . Za c r P
The forgoing instrument was acknowledged efore me The forgoing instru nt was acknowledged before me
this 3 0 day of /717 ,20/b by this3 0 day of 20/8'by
(tea/'y Ftryst C-4,6,, r-f'vt":
Name oicperson making statement Name of peison making statement
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced ----
•;;.11;. EMANUEL GAGE
°. `-MY COMMISSION#GG116741
/� L tiP ��1. EXPIRES June 20:2021
Si nature of o P ' of FI UEL GAGE (Signature of N Publi;-S#ate of Flori a J
( g ry #fie ��M C g ry l I 1
' '` •`i MY COMMISSION#GG116741
Commission No. EXI�IJune 20,2021 Commission No. (Seal)
i
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.8/2/17