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SUPrPLE1VIENTAL CONSTRUCTION LIEN LAW INFOR:IVIATION:;
.,
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY. Not Applicable
Name: Name:
Address: Address:
City$ State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER:
Name:
Address:
City:
Zip: Phone:_
Not Applicable
BONDING COMPANY:
Name:
Address:
City:
Phone:
Rot Applicable
OWNER/ CONTRACTOR AFFID�fIT: 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 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
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Signature of Owner/ Lessee/Contracter as Agent for Owner Signature of Contractor7cicense Holder
FLORIDA STATE FLORIDA
COUNTY OF 5T COUNTY OF Luc t lie,
The •r I • '• '• •' • • _• • '••'• before me
th day ore6f • day of by
Name of personof person
Type of Identification Type of I tion
Pro ced
Pro e
Personally Known OR Produced Identification Personally Known OR Produced Identification
(Signature of • • of • ary .�• i
r. Ta
Commission No..
F Commission No.
. ...M1 i. - 4 .,Eyoim .. 61402()
• FRONT ZONING SUPERVISOR PLANS 'VEGETATION 1 TU •TLE MANGROVE
REVIEW REVIEW REVIEW REVIEW
COUNTER REVIEW REVIEW
DATE
COMPLETED