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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: dame:
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 Name 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 1 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.
Sig re of owner/Lessee/Contractor as Agent for Owner Signa ure of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF cr. COUNTY OFi
The f rgoing instru nt was acknowledged before me The fa going instrupent was acknowledged before me
this, /day of —K�- 24 by this day of �•w1 �� .Z()� by
me of person making statement ame of perso"aking statement
Personally Known z-�_OR Produced Identification Personally Known ►/ OR Produced Identification
Type of Identification Type of Identification
Produced Produced
of Florid MARTIN (Signature of Notary Public to rida) MIKE MARTIN
{Signature of Notary ,of Florid { g ry `tmp
Notary Pull
u Ile-State of Florida gr° .`��' Notary Public-State of Flo i
`• ` 'i Co on#FF 216951 Commission No. « :• (SOmOmission#FF 216911
Commission No. ��
My Comm.Expires Apr 5,2019 My Comm.Expires Apr 5,
,�'' + ;;''''• Bonded through National Notary Assn, h'�'°F"`�''• Bonded through National ptr.
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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