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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number: �, • ��1�
Building Permit 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 INPROUEMEN11LOCATIO
Address:
Legal Description:
PropertyTaxlD#:
Site Plan Name:
w:
Project Name:
Setbacks Front l 2 Z Back: !r Right Side: _39� Left Side:
Haamonai worK to De. permrmea unaer rnis permit — cnecK aii mat apply:
_Mechanical _ Gas Tank —Gas Piping _ Shutters
Electric —Plumbing '// _ Sprinklers _ Generator
Total Sq. Ft of Construction: 676/ " Sq. Ft. of First Floor: _
Cost of Construction: $ 7� Utilities: —Sewer —Septic
Block No.
Windows/Doors
Roof Pitch
Building Height:
OW ; �R/l iCONT�R:
Name
Address V,QS;'. , fi✓8 Q (
6' ,ram,-- s.
Company
�'
City r � � State.
i. Y
Address. 3 h
, a r-
Zip Code: 3l "Fax
City: 'f' +-'-...>,`a ., �,. State:
Phone No.
Zip Code: 3 Fax: 4"7
E-Mail:
Phone No 1_'�2_-Z Dt-rr3 ?,
Fill in fee simple Title Holder on next page ( if different
E-Mail
State or County License Ck—Ia.SS
from the Owner listed above)
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMEN?AL gig' i UGTION LIEN LAW NFORMP►Tf N;
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 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
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.
9 CVL4_
Signature of Owner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
COUNTY OF S 1 L LC (X
STATE OF FLORIDA r U�
COUNTY OF S1 L Z"
The forgoing instrument as acknowledged before me
this 0 day of.&!'E 20& by
The forgoing instrument was acknowledged before me
this day of 2020 by
D
Name of person making statement.
Personally Known �9 OR Produced Identification
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
(Signature o otary Public- State of Florida)U
(Signature of Notary State of Florida )
Commission No. r e
Public S b atFlalsla
Ke G Dra wdy
Ka
rPublic-
Commission NotJi CA Nowt' �ofFlafdo
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REVIEWS
4
FR
Expjrrts 02111
3
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PLANS
VEGETATION
SEA URTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
lev.8/2/17