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S 'PPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: � Name:
Add ress: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FE SIMPLE TITLE HOLDER: Not Applicable BONDING COMPANY: Not Applicable
Name: Name:
Address: Address:
City: City:
Zip;: RhoLne: 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 w+th 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, cons0t with lender or an attorney before
commencing work or recording our Notice of Commencement.
Sigharltbre of Owner/Lessee/Contractor as Agent for Owner Sign Lure of Contractor/License Holder
STATE OF FLORIDA � STATE OF FLORIDA r_
COUNTY OF � k �L a COUNTY OF G,
The forgoing instru nt was acknowledged before me The forgoing Instr�tm�gt►+�+as acknowledged before me
this day of J �, 7. _ .20_L<j�by this day of ,v 20
fume of person king statement i N of person making statement
Personally Known OR Produced Identification Personally Known /_OR Produced Identification
Typelof identification Type of Identification
Produced Produced
(Signature of (Signature of Notary Pub1 Mate r1wiftT
1N ,.waY'p"a, MIKE:MARTIN
: ¢�+ Notary Public of Florida a°� UB`%; No� ypiic state of Florid
Commission N ( Commission No. - t i�
o , mission F 216251 _ •= lion FF 216951
My Comm.Expires Apr 5,2019 ;�,fR Vie:= My Comm.Expires Apr 5,201
1 a ed through National Not Assn. ° ���� Bonded through National Notary As 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