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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED ®,
Date: Permit Number:
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Building Permit Applica ion 8 0.Nnr
Planning and Development 5ervices
Building and Code Regulation Division la',3A 0%awn MA .
2300 Virginia Avenue,Fort Pierce.FL 34982
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Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residentia
PERMIT APPLICATION FOR:
I M T-9,IM-1-9 S 9 INPROUEMENT LOCATION:
Address:52D ,Q
Legal Description: Q :5—r-C4,, PO'Lle—
Property Tax ID#: �1f — 4;57/Lq 0dr�-C, < Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: _LekSide:
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DETAILED DESCRIPTION OF WORK:
C®NSTRUCTfON INFORMATION:
Additional work to be pertormed under this permit—check all t. at appy:
_Mechanical _Gas Tank —Gas Piping _Shutters _Windows/Doors
_Electric 'Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $ t���` oy Utilities: —Sewer _Septic Building Height:
OWNERf LE=�S�SEE: CO TRA OR:
Nam 1 U�)(J Name:
Address: S 70? Company:
City:/ f//1^-e State:r/ Address:
Zip Code:- Cl Fax: City: State:
Phone No.7? '33 a '7 6�j Zip Code: Fax:
E-.Mail: 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.
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 thepermit holder to build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaw's 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 wor ecording your No ' mmencement.
�ignature o Owner/Less[ele.//CCoontractor as Age fIpFbwnllr Signature of Contractor/License Holder
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STATE OF FLORI 4 68 9 STATE OF FLORIDA
COUNTY OF m� COUNTY OF
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The f9j&oing instr men as acknowledge e I The forgoing instrument was acknowledged before me
this 'day of J 20 b =°NN'"9 this day of 20_ by
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Y( am
e of person acknowledging) (Name of person acknowledging)
(Signature of N ry Pu ic-State of Florida) (Signature of Notary Public-State of Florida)
Personally KnowiT� OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced _ ` f� Produced
Commission No. (Seal) Commission No. (Seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
ev.