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ALLAPPLICABLEINFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: I �O — Permit Number:
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Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34981
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential ie
PERMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT LOCATION:
Address: I(
Legal Description: vl� Q J
I don
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Property Tax ID#:)3Q J-X00-0 13-oC0-4 Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION OF WORK: 1
Irk
CONSTRUCTION INFORMATION: 1
Additional work toe pertormed under this permit—check a appy:
HVAC Gas Tank Gas Piping _Shutters Windows/Doors
1-1Electric ❑ Plumbing ❑Sprinklers E Generator ❑ Roof Roof pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $ I�, �� Z. — Utilities: O Sewer ElSeptic Building Height:
OWNER/LESSEE: CONTRACTOR:
Name Name:
Address: Company: "�h_uc:[kts 100
City: State:el. Address:
Zip Code: Fax: City: State: T l.
Phone No. 2 —Z S Zip Code: Fax: — to o
E-Mail: Phone No. 22nb
Fill in fee simple Title Holder on next page (if different E-Mail: Q an1'e Ur 'Ld� Inc ,C
from the Owner listed above) State or County License:
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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
commencing work or recording our Notice of Commencement.
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Signature of Owner/Lessee/Contractor as t for Owner Signature of Contractor/Licenseder
STATE OF FLORIDA � STATE OF FLORIDA � (��
COUNTY OFTJ%_a' C ��Q (L COUNTY OF rr�(`II 2s>Q �Z
The foriwing instr ent as acl nowledge efore me The fo o' instrument was acknowledged before me
ill
this ay of 20�by this ( day of L.l�uCS 20 by
l L . � L ,eGt5k
Name of person making statement Name o person making statement
Personally Known Se OR Produced Identification Personally Known S—OR Produced Identification
Type of Identification Type of Identification
Produced Produced
mle�_Z?ej
(Signature of Notary Pubic-State of Florida ) (Signature of Notary Publili,Ttate of Florida )
Commission No. (Seal) Commission No.
J,„„Pl'w LETI I f
Notary Public-state of rI and
• Commission#GG 103721
;.•Niv i��'•� ETICIATREIO - -- ---- ---
•. ISended through Nation I Noi,'y A,,,REVIEWS FRONT f4dotary �+ fPLANS VEGETATION SEAeTilifi VE
COUNTE =.� Com is o
�IyCom .Ex 21 REVIEW REVIEW REVIEW REVIEW
DATE `,` Wild th Dugh National Notary ssn.
RECEIVED
DATE
COMPLETED _
Rev.8/2/17