HomeMy WebLinkAboutBuilding Permit (.' = BUILDING & CODE REGULATION DIVISION
2300 VIR INIA AVENUE
FORT PIERCE, FL 349$2
772-462-15 3
---- - F AX772-462®157
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
RE:
Permit
Credit Card Users: 1.5®/o Surciiarge added per transaction.
Payments must be received in this department by 4:00 PM for transaction to be
processed that day, if not it will be processed the following business day.
r
VISA MASTERCARD
Credit Card Number
Expiration Date Zip Code
3 digit security code
Amount $ + 1.5% surcharge
Business Name: �1. f;tiir
Authorized Signature:
Print Name: � ,,`� o
Phone:
Fax:
Comments:
SLCPDSD Revised 4/01/2010 EN
ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
Building ermit 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:
PROPOSED IMPROVEMENT LOCATION
Address: 2"D yi_->ficl !Jt
Legal Description: a r\'Is Liu e � ' �, (��` co
Property Tax ID#: Lot No,
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION;OF WORK
CONSTRUCTION.iNFQRMATION
Additional work to (e Per orme under this permit—check a apply:
OHVAC FI Gas Tank Gas Piping _Shutters Windows/Doors
11 Electric K Plumbing Sprinklers []Generator Roof Roof pitch
Total Sq. Ft of Construction: S Ft.of First Floor:
Cost of Construction:$ Utilities:0Sewer[]Septic Building Height:
OWNER/LESSR :.'. CONTRACTOR
Name LC onclrC: OW\I-K Name: 11AV
Address: OG Q Company:- b
City: - j e r C C ate:VL- Address:
Zip Code: cI Fax: City: State:—F—L
Phone No, 369.- (DoLl- q S 1 Zip Code:32 1 A"_ Fax:
E Mail• Phone No. 32-11- 9
Fill in fee simple Title Holder on next page(if different E-Mail: RA\1)0 a(� -W ice
from the Owner listed above) State or County License: M `Jl
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION;(IEN LAW IN. ORiViATIpN:;
DESIGNER;ENGINEER: A 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 Cuun ii--'e,iw representa'rion that is granting a permit will authorize the permit holder to build the subject structure
which is in con�lict with any applicable Home Owners Association rules,bylaws or and covenantsthat 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.
Signature of Owner/Lessee/Contractor as Agent for Owner signature of Contractor/License Holder
STATE OF FLORIDA — i STATE OF FLORIDA
COUNTY OF_ I r��et1 -Cl—
The OF t f V 0.r
The forgoing instrument was acknowledged before me The Forgoing instrument was acknowledged before me
this 4l�day of Y 1�a rc,v. 20A by this day of }ffi 20J-2 by
( l/
Name of pers making statement Name of�n aking statement
Personally Known Y OR Produced Identification Personally Known VOR Produced Identification
Type of Identification Type of Identification
Produced Produced
0/(LAA
(Signature of Notary Public Sta re of Notary Public- t
DIAt,IET.WET vr'
iq' ° '; '� .t"C' UkNE 7,LAPETE
Commission No. i#: 14al) MY COMMISSION#GOo mi ion No. =j• �SeJWCOMMISSIONIG00cro
=" o: EXPIRES:Jui 3l,2'y 20 zu sr r,•; EXPIRES:July 31,2
?g lt,• BWod Tiuu Nolary Pubul; ndenrtilero y: � flooded 1hN Not"Pub5o J
I
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE I
RECEIVED
DATE i
COMPLETED
Rev.8/2/17