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DIESiraNEEP4CNGNINEFzR,M"NotAppl!Mca5l,e MORTGAGE COMPANY: Not Applicable
Name: Name.
Address: Address:
City: State. City:
Zip: Phone Zip.: Phone:
FEE SIMPLE TITLE HOLDER: �C Not Applicable BONDING COMPANY* X -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.Lucia County makes no representation that Is granting a permit will authorize the permit holder to build the subject structure
which Is in conict 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 ail 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 IMPROVENENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND
POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF-COMMENCrMENT."
Signature of orfer/Lessee/Contractor as Agent for Owner Signature of Cont License Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OFSTLUICE COUNTYOFsTLuctR
The 11019?Ing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this �0 day of 20 let by this-2-0 day of by
JOHN PANKW JOHN PANKOZ
Name of person making statement. Name of person making statement.
Personally Known OR Produced Identification Personally Known X OR Produced Identification
Type of identificationType of identification
Produced
K014%11.ErIASDgVr5 Produced
0
KONNI LENAE DEW'T-r
IT'r
tall""
Notary Pubrio-State of ROO
res 9ee 19,2924
(Signature ofNotary PubIVA*4""ffM_ (Signature- Notary of NotaP Stontil NtMIyA�M....
Commission No, 66)wpl(� (seal) Commission No. 7 (seal)
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGE-rATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
GATE
RECEIVED
DATE
COMPLETED
Te-v-.ZM 19