HomeMy WebLinkAboutScan_0059ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: 6U,
-1
Building Permit 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
PERMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT LOCATION:
Address: 31i�s
Legal Description:
C
Property Tax ID 4: �t Gi 1 1 ~` ��(� Lot No.
Site Plan Name: I Block No.
Project Name: [' [�[ a Y n CuYQ
Setbacks Front 12-3 W Back: flight Side: Left Side:
DETAILED DESCRIPTION OF WORK:
CONSTRUCTION INFORMATION:
Additional work toe nertormed under this permit— check all that appy:
HVAC DGasTank []Gas Piping _ Shutters Windows/Doors
Electric 0 Plumbing 05prinklers ElGenerator E]Roof Roof pitch
Total Sq. Ft of Construction:
Cost of Construction: S ";2 5-'Q - 0-0
SFt. of First Floor: _
Utilities: Sewer []Septic
Building Height:.
OWNER/LESSEE:
CONTRACTOR:
Name +C 6 CA CL -e—,
Name:
' l
Address: )e :
City: l� U State: i7 ---
Zip Code: Fax:
Phone No. , —PS-- Z
Company:
Address: J b'
City: �,i State:
Zip Code: Fax:
Phone No. G- 1
E- M a i I:Eloa Y I IL g)"I C0
Fill in fee simple Title Holder on n xt page ( if different
from the Owner listed above)
E -Mail: 1r Uy1
State or County License: i�l� 4v�
If value of construction is $2500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: Not Applicable
Name:
Address:
MORTGAGE COMPANY: , Not Applicable
Name:
Address:
City: State:
Zip: Phone
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER: Not Applicable
Name:
Address:
BONDING COMPANY: Not Applicable
Name:
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
commencinEz work or recordinE vour Notice of Commencement.
tlere
Signature of ontrac or/ icense Holder
Signature of ner/ Lesse /C dntractor as Agent for Owner
STATE OF FLORI
STATE OF FLORIDA
COUNTY OFA Vf? io
COUNTY OF Mait-fi n
The forgoing instr e as acknowledg efore me
1 f
The for ing instrument was acknowledged before me
this day Seot.r'y.A) >', 20 1�y
this day of _ _ by
of
Name of per�oikmaking statement
Name ersary� king statement
Personally Known OR Produced Identification
Personally Known ✓ OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
(Signature of Notary Publi Sta e o iorida )
(Signature of Notary Pu blicgStati o Florida j
C � �03 I
Commission No. V
P'" p' J RA CULPEPPfR
mission No. 1i�7 a� 1 .• RY PLa('e ( ey
����',"'��.. LAURA CULPEPPER
�. r : Nbsary ublic • Siate of Flora
a �? Notary Public • State of f
rida =' : • = Commission # FF 967031
Commission # FF 9670
t My Comm. Expires Mar 2, 20
yCOMM. xpires Mar 2
��i OF F4�yY�
2020
Bonded t
rough National Notary As
REVIEWS
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COUNTER
REVIT\9 FTEV1EVV
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REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17