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04/09/2019 14:02 7726921094 PREMIER PAGE 03/03
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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 installatlon 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 thepermit holderto 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 Assoclatlon 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.Ducie 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 JOB SITE 13EFORE THE FIRST INSPECTION. EF YOU INTEND TO 011rrAIN FINANCING, CONSULT
WITH YOUR ILMDER OR AN ATTORNEY ISEFORE RECORDING YOUR NOTICE OF COMMENCEMENT."
Signature of Owner/Lessee/Contractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA �I ���I�. STATEOUN�OFORIDA ��
COUNTY OF_ [ T.
The f r ing instru enc w acknowledged before me The f r ing instru nt wa acknowledged before me
this 7day of � 20� by this y o day of 7612 by
,,,�'( ryl j�E ISS • • � ..._ �c,y'1�`l. (�.�ti !S . _ _
Name of person making statement. Name of person making statement.
Personally Known ✓ OR Produced Identification Personally Known +"' OR Produced Identification
Type of Identification Type of Identlficatlon
Produced Produced
k� rLAQ-0 —
(Signat7ur4 of Notary P ic-State of Flo da) (Signature ot Notary Public-State of FloridkU
commission oa s ----f-- ea Commission .a ..... APRItBRUMLEY I (Seal)
issio060=1194 a ExpResAprll ii'-2022 +
wY rain mw�m No
REVIEWS ERViSOR PLANS V GROVE
COUNTER REVIEW` ' REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETER
re—v.-2777-19 '