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DESIGNERANGINEER: No Not Applicable
MORTGAGE COMPANY, Not Applicable
Name:VIOLA HOLDEN Name*0
ICI ICHAEL ROTH
Address:VIOLA HOB-DEN 5149 TURTLE CREEK P-.FORT PIERCE Address: 5149 TURTLE CREEK PL.
!
City, FORT PIERCE State: City: PORT ST.LUCI E State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER* Not Applicable BONDING COMPANY: Not Applicable
Name: Nar e:
Address:1862 SW.HI CKOCK TR. Address:
City: City:
Zip. Phone. Zip. Phone.
OWNER/CONTRACTOR AFFIDVIT:Application is hereby rude 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.
t.Lucie Countymakes no representation that is granting a permit will authorize the errnit holder to build the subject structure
which is in con ict with any applicable Hone Owners Association rules,bylaws or an 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 trice 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 four Notice of Commencement.
1
of 0*07
Signature of owner/ see/Contractor as Agent for Owner Signature of Contra r License Holder
STATE OF FLORIDA � STATE OF FLORIDA
COUNTY'OFCC� COUNTY �
The forgoing instrument was acknowledged before me I The forgoing instrument was acknowledged before me
this Ada f ( t this r� day of 0 b
s o "by y y
t
� s making - arne i) r'erson making statement
Name�f per�or�ma �ng statement #� � #; g
Personally Known OR Produced identification Personally Known -OR Produced identification
Type of identification Type of identification
Produced Produced
g1g
i
(Signature of Not ry Public-State of Florida (signature of Notary blic_State of Florida
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Y Pie! ' ���`��� �. � ,. e�����y p�e�i�P `'� ��' �.,
Notary Public-Sat o ! � �: Noiary Public-��at�of Torch
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Commission Fir'?4� •k r�{{_µ •+ Commission#FF 240343 _
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R RE I EW REVIEW ! REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. / 1