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Fee Due:
"
Permit #
St. Lucie County Building & Zoning
2300 Virginia Avenue Ft. Pierce, FL 34982-5652
Tel. 772-462-1553
APPLICATION FOR ROOF PERMIT
SEE REVERSE SIDE FOR INSTRUCTIONS
1. Location/Site Address:, .;; 7 O'~ a·CÞ I _
2. Parcel ID Number: if4 () 5 · (ø ð 1 4
Office Use Section Townshi
Only
3. Description of Project or Work Activity: ~D¥=
4. Total Roof Area (square feet): l S
5. Roof Pitch:
Lot ll2-
6. Type of Roof:
þa..Fiberglass Shingle
DTar & Gravel
DOther (specify)
o N.O.A - Product Approval required for All Types of Roofing Material
o All Commercial Roofing Requires Design by an Engineer or Architect (two Sets)
D Barrellfile Ceramic
DModified Bitumen
D Wood Shake Shingle
D Metal
7. Owner Information
Name: A ICi 11( ¡j µ
Address: q; ';) 0 .3
,~;:¡ ,; í b'}
C<--<-..Þ ~ L.
8. Contractor Information
FL Reg/Cert #:
County Cert#:
City:
·Zip:
Jf ~~~f1~
:3 '-19'1 ì
,
State:
//~.
Business Name:
Phone: '77;.< - 9bh -/3..7/Phone
ax
9. Value of Construction: $ --0 -
Note: Dry-in and Final Inspection Required.
Additional inspection may be required per Product Approval
OWNER'S AFFIDA VJT: I certify that all of the information contained in this application is correct and that all work will be done
in compliance with all applicable laws regulating construction and zoning.
K 'd/CinC/è #~¡/7 '--ð--~-A-~-~¡:¡'~
PRINT QUALIFIERS/O\\'NERS NAME SIGNATURE OF QUALIFIER/OWNER
STATE OF FLORIDA, COUNTY OF St-. la-.LLLL.Q ACKNOWLEDGED BEFORE ME THIS 8 DA Y OF
Jan,20~BY 0tanLkL Qa ~',n WHOISPERSONALLYKNOWNTOMEORWHOHASP~
, J 'op' lC·S'T!\lt. Or hea
t-"\ l \ l AS lDENTIFICA TION. NO"T!\RY tJ"\ .: \'-:3;' ";,# GOYCOC
,,, "" BE"" alLl . 1'\5B9694
...' \ & "~ ß .t.... . n '* D )J .
§ ~ ¡ ('.(rcr.\nÙ13~\O. . y 01~ 2.00~(seal)
TYPE OR PRINT NAME OF N\>~l ~\teS\~N\)iN~ co.. l~C
;'J1~ " tt..'.~.'~~_,.~:~;: ':~\¡\1C i
CO~1MISSION NUMBER b(j:,~0't:.j) df.~"'-
S\. Lucie Count)' Roof Permit Application rev. 7/18/05 dmg
Residential Roof Dry-In Affidavit
8t Lucie County, Public Works Department
Code Compliance Division
Building Permit # 04-( d-' l ~ 0 Lf
· Owner's Name ;6 / c{ lJ C ¡; P
· Owner's Address 37 0 '"3 Ú-t t<
Contractor
7( C<jd ~ KJ-
.
(--
Contractor's Address
I certify that: The required Lapping and Fasteners of the underlayment
(roof felt) and flashing have been installed in accordance with Chapter
15 of the Florida Building Code and Chapter 9 of the Florida Building
Code, Residential with approved revisions and meet the requirements of
the product approval.
I understand that by executing this Affidavit I hereby relieve St Lucie
County of any liability with respect to the installation of these materials.
Signa re of Notary Signature of Notary
~r¿,~ Gr)~ c.JJ~
Type or Print Name of Notary Type or Print Name ofN MY PUBUC-STATE OF FLORIDA
\\\tl"1 B
..,\ I, eatriz G h
Commission No. (Seal) Commission No. ¡ .lB4:J~ " .oycoc ea
~#,~l CO~IIl.1SSlOn # DDS89694
'1111""" Expll'es: JULY 01 2007
No Faxed Copies, Only Original Notarized Copy will be acceplllit:H1Wt\lli\,\TIGB8NfJINGc:o"INc,
OWNER/CONTRACTOR'S SIGN URE
STATE OF FLORIDA
COUNTY OF
The foregoing inst ent was acknowledged
before me this day of , 20 _, by
, who is personally
known to m or who has produced
as identification.
dmg revised 12/22/2006
· HOME~~1i~~ÆuRE ~~
STATE OF FLORIDA
COUNTY OF st. LuJ-Ù
The foregoing instrument w~ acknowledged
before me this'ò day of J£:)(1,~, by
~lOt fL!JLt, ~ ~ Y"'.. , who is personally
known to, me or who has produced
( , t D a' ntification.
· .
.sø-h~,
Building
Receipt
Code Compliance Division
2300 Virginia Avenue
Fl Pierce, FL 34982
Phone: (772) 462-1553 Fax: (772) 462-2522
http://stlucieco.gov/ce
Date: 08 January 2007 Receipt #: 0000049715
Job Address: 3703 AV L 'ennit Number: SLC- 0412-1304
Received By: serranob Amount: $50.00
Paid With: CA :redit Card Number:
Check Number:
Paid By: BLANCHE RAGIN Sign: