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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
structure. conflict
leafsie consult w with applicable
lome Owners Assoc Association iandrreviewyyour deed for any restrictions which which maor
aprohibit such
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.
Signature o r/ Lessee/Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF LllChr?
The forgoing instrument was acknowledged before me
this day of MOV• 201% by
Name of person makift statement
Personally Known_ OR Produced Identification
Type of Identification
Produced
Sign a Contract/License Holder
STATE OF FLOC r2�
COUNTY OF LU CI
The for oing instrument was acknowledge before me
this day of by
7C) 11 Lc.
Name of person maMg statement
Personally Known V, OR Produced Identification
Type of Identification
Produced
(Signature of` � Y Public -(gate d�ttii & )
Si nat a of, Nn U IC �e'•,
( g PPr a L N t ;'o ���•. Notary Public -State of Florida
= ? • li q PueNc -State Q;k tide Commis o = : •= Commission #► FF 91 1x1
Commis 8 N #F FF 912591 '.;� My Comm. Egms Oct 5, 201
my COW. Expires Oct 6. 2019
9dxlNtbou�N:tlo�plNotsryAs�
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REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17