HomeMy WebLinkAbout1) NOTARIZED Building Permit Application 3 total pagesAll APPLICABLE INF٥ MUST BE CoMPlETED F٥R APPLICATION TO BE ACCEPTED
ةDate^Permit Number:
ا,'-ااوا
COUNTY
OR
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2500 1/،'٢ฐ،'ก,'0 Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercia!Residential
PERMI( ^PE:
PROPOSED IMPROVEMENT LOCATION:
Property Tax ID #: เ\เ n ' z ๐3, · Οθα3*-000 ‘
Address:
دهlot No.
Site Plan Name:
Project Name: -
Block No.
DETAILED DESCRIPTION OF WORK:
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CONSTRUCTION INFORMATION:ببيت-¿:00)С>53^5Additional work to be performed under this permit -check all that apply:
Gas TankMechanical Sh— Gas Piping
Sprinklers
utters Windows/Doors
Electric Plumbing Generator Roof Pitch
Total Sq. Ft of Construction:Sq. Ft. of First Floor; _
Sewer —Septic
ج<٠Cost of Construction: $ /3 ?)/,r/ł ธ Utilities:Building Height:
OWNER/LESSEE:CONTRACTOR:
Name:p ŢmСотрЭ-
ΰΧΐ.ίυΤΑ Сктч
Zip C-
Phone No
State: flř
Vax·.
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Name
Address:
City:
Zip Code:.
Phone No.
E-Mail:
Fill in fee simple Title Holder on next page ( if different
from the owner listed above)
State:
Ε-Mall^
؟ ؟ ةState or County Licens^gC t
٩د,
If value of construction is $2500 or more, a RECORDED Notice of Commencement is required.
If value of HVAC is $7,500 or more, a RECORDED Notice of Commencement is required.
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state of F!o٢!da Acknow!edgement Notary Cert!f!cate¡ΙΛ')Λ :r\ị P?rY\Ặ اد٦\،/\.:ء٦
STATE ٥F FIOR.DA
CoUNTY OF rf١4;،
/¿UlZri p.)‘/زًاص a notary pub!!c, persona!!y appeared by phys!ca! presence,
me on the bas!s of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the attached
[name of document] instrument and acknowledged to me that that he/she/they executed the same in
hls/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) or
entity upon behalf of which the person(s) acted executed the instrument. I certify under PENALTY OF PERJURY
under the laws of the State listed above that the foregoing paragraph is true and correct. WITNESS my hand and
official seal.
before me.who proved toOn
Personally knn١٨Î^
Produced identification
OR
Type of identification produced:
د
[Signature of notary public]
My commission expires
MARGARETE. TIERNEY
N٥!ary Public, Stale of Florida
Commission# GG140124
íị I Μ۴ comm, expires Sept. 16,2021
مأل
؟؛
Official Seal
3 ،,โ ؤ
05-74-0433NSB 02-2020
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DESIGNER/ENGINEER:
Name^
Address:
Not Applicable M.RTGAGE COMPANY:
Name:
Address:
City:State:City:State:
Zip:Phone Zip:Phone:
z
۵FEE SIMPLE TITLE HOLDER:
Name:
Address:
otAppllCableNot Applicable BONDING COMPANY:
Name:
Address:
City:.City:,Phone;Zip:Zip:Phone:-
OWNER/ CONTRACTOR AFFIDVIT: Application Is hereby made to obtain a permit to do the workand Installation as Indicated.I certify that no work or Installation has commenced prior to the Issuance of a permit.
ةهةجأ؛ا:٠؛»:ججةةجججا؛ساجلاةئجةهأج;يحعستلل'ereby agree that 1 will, in all respecte, perform the work ؛^ 5 rerestedperrnit, I d م،grontlngof 1า٥”|٠^ท:ฟ٠ฌร٥!C^ntyAmendmente.P icu؛؛and٥st٥؛؟in accordance with the approved plans, the Florida Building Cod
The fallowing building pẹrmìt applications are exemptfrom undergoing a full concurrency review: room additions,accessonr structures, swimming pools, fences, walls, signs, screen íoo^s and accessory uSes to another non-residentia l use
WAING TO owner: your faire to record a notice of COMMENCEMEOT ÃV RESULT IN YOUR PAYINGTWICE FOR MPTOVEMENTS TO TOUR PHOPEHTT. A NOTOE OF COMMaittMENT MUST BE RECORD. aNDPORTED qjN THE JOB SITE BEFORE TOE RHST INSPECTION. IF TOU lOTEWD TO OBTAIN FINANCINC, CONSULT¡YOUR LENDER ORANATTORIBgQRE ffi CORDINC lUR CE OF COMMENCEMEOT.
Ü ặlatUrè of Contractor/License Holder دلSignal.■è ๙ Owner/ Lessee/Contr:as Agent for Owner SI.
STATEgF FLDRI^COUNlYOpUH^ếr/)STATE OF FLORIDA
COUN^OF.
The f۶!ng İnstr^^nt w^acknowledged before me
هصتئئك
Name of person making statement
Personally Known
Type of Identification
Produced
7
//qR Produced Identification
The forgoing Instrument was acknowledged before me
this dayo.by
Name of person makln^atement.
Person^Produ؛^.produced Identification
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*ilt-(signature of Ν'
Commission No (Se
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íioùiàẾ بCommissionV al)
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REVIEWS FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR
REVIEW
PIS
REVIEW
VEGETATION
REVIEW
SEA TURTLE
REVIEW
MANGROVE
REVIEW
DATE
RECEIVED
DATE
COMPLETED
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