HomeMy WebLinkAboutFails AC Change out Permit App pg 2 001SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
Address:
City: State:
Zip: Phone
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name:
BONDING COMPANY: _Not Applicable
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 Count 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 attornev before
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Signature of Owner/ Lessee/Conti orAgent Owner Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF �t- LUGC� COUNTY OF
The for oing instrument was acknowledged before me
this day of PV6 20_6 by
�l i e( (- ROW
Name of pers making statement
Personally Known V OR Produced Identification
Type of Identification
The forgoing instrument was acknowledged before me
this day of AW I 20 Iq by
Name of person Oa king statement
Personally Known OR Produced Identification
Type of Identification
(Signature of Notary P o- Sia ,Af o ' (Signature of Notary P�i}ilic- State of Florida)
„u..,,,,, CHFIS'iNE J. CONWELL
Commis R ''^�a'•., State b61)na
=� Commissi Nps "'tis CHRISTINE.; COtedl)
Commission # GG 017839 ; a° `�; Notary Public -State of Florida
My Comm. Expires Aug 21.2020 • . _ . Commission # GG 017839
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Bo a ro ��'•:: o; ; „��'� nde t h taz
REVIE Z NTNG SUPERVISOR PLANS y
COUNTER REVIEW REVIEW REVIEW f REVIEW I REVIEW
DATE
Rev. 8/2/17
REVIEW