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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: d Permit Number:
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
PERMIT APPLICATION FOR:
Address:
Legal Description:
Property Tax ID #: Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
,Mechanical _ Gas Tank _ Ga
Electric _ Plumbing _ Sp
Total Sq.. Ft of Construction:
Cost of Construction: $ `Tl�
liping _ Shutters
nklers _ Generator
Sq. Ft. of First Floor:
Utilities: —Sewer —Septic
Windows/Doors
Roof Pitch
Building Height:
OWNER%LE=�SSEE:
CONTRACTOR:
Name
Name:.�f.��a=�
Company: ,_L.4,s�-
Address:'736�o� C1G�yrh9,� �� dot,
City: State: J�C,
Zip Code: _741�' 9_1 Fax:
Phone No. 942<- 538—cell
Address: 3L>3,d 01--;
City: State:
Zip Code: Fax:
Phone No !7_72--
E-Mail: --_
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
E-Mail 6 J 4.6 a 5 (? ���,. �✓�
State or County License / !q€G
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
St11PPLEMEN SAL CQNS RUCTIr�N LIEN LAW INFORMATIQN:
DESIGNER/ENGINEER: -4 Not Applicable
Name:
Address:
City: State:
Zip: Phone
MORTGAGE COMPANY: ✓ Not Applicable
Name:
Address:
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER:y Not Applicable
Name:
Address:
City:
Zip: Phone:
BONDING COMPANY: Not Applicable
Name:
Address:
City:
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-perm it 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 t'he jobsite
before the first inspection. If you intend to obtain financing, consult with lender or an attorney before
commencing work or recording your Notice of Commencement.
,
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Signata of Owner/ Lessee/Contractor as Age t for Owner
Si u o ontra r/ icense Holder
STATE OF FLORIDA
STATE OF FLORIDA�
COUNTY OF
COUNTY OF
The forgoing instrument was acknowledged before me
The forgoing instrument vos acknowledge4efore me
this day of 20_ by
thisday of 70�-Q by
Name of person making statement.
Name of person making statement.
O
Personally Known OR Produced Identification
Personally Known OR Produced Identifica
Type of Identification
Type of Identif' tion
32Q�
Produced
Produced
��o voF`cF
Quoin
(Signature of Notary Public- State of Florida)
(Sig ure of o ry Public- State of Flor' a )1
Commission No. (Seal)
off,
C mission No. ' (Sea
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEA TURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED I
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