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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE CCEPTED
Date: ermitNumber: llnol(0-8
Building Perm t 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
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PERMIT APPLICATION FOR:
PR• •OSED INPat3VEMENT LOCATI �
Address: S fo if !. Uj a —
Legal Description:
Property Tax ID#: 160 D Lot No.
Site Plan Name: Block No.
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Project Name;
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Si tbacks Front Back: Right Side: Left Side:
D TAILED D �SCR�LPTION OF WOR
L1 T S ONNO 1. S�c/t�
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CaNSTRUCTIO NFOR
Additional work to. a pe orme un er.t is permit-check all that appy:
V Mechanical _Gas Tank' Gas Piping Shutters - _Windows/Doors
_Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. f First Floor:
Cost of Construction: $ �J I S o Utilities: _ ewer . _Septic Building Height:
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0 NER/LE:r.S�5EE: CON RACTOR:
Name Name:
Address:�o�(offA 1 1.1 S) Comp ny:��� ,n �
City: State:�� Addre s: 434 4Axff4T1' ;
Zip Code: Iq ao" Fax: City: State:�i
Phone No. —)q 33:-2N C Zip Co e: '3 3�o . /Fax:
E-Mail: Phon No .% _ -� (y 3 643
Fill in fee simple Title Holder on next page(if different E-Mai LQ,Q-Pa 'A f3o6Q 4bhP7
from the Owner listed .above) State r County License Ch-(f- /$/i 64�
ILif value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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St1PP'LENIENTAL C�NS1' CT10N L1 �N LAW 1fU°FORMAT 0'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 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
commencm o k or recording our Notice of Commencement.
ature r/Lessee/Contractor as Agent for Owner Sin ture of o actor/License Holder
STATE OF FLORIDA STATE OF FLORID
COUNTY OF �k ..a� COUNTY OF
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this day of 20_ by this day of 20_ by
(Name of person acknowledging) (Name of person acknowledging)
?`�Z
( ign ure Notary Public-Stat of Florida) (Sign ur o otary Public-State Florida)
Personally Known • OR Produced Identification . Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced _ Produced
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LASHf�IiPla INGRAM RY e% tA4J iAFJN i rvon M
""` ° ,`� tv�otar Public-State of Ion
{�aY "O,, �blic-State of Florida y
(Seal) Commissio o. \)a _. . expires Dec(,�ea '$
Commission No. -� Plc ..
pAy Comm:cxPires Dec 20.201E c Fuc; (1
' l' Commission ;�FF 177249 =.9. F,. Commission #FF 1.77249 n r(
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REVIEWS FRONT ZGN'f SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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