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All APPLICABLE INFO MUST BE CC
Date: 0(c),I6.2 0
ED FOR APPLICATION TO BE ACCEPTED
COUNI
Building Permit
Planning and Development Services
Building and Code Regulation Division Commercial_
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Permit Number: a�aG'a`i�5
JUN 18 2020
I ST. Lucie i
Residential
Address:5(005 Killarne.l civR
PropertyTax ID #: 1301- (, 2J- 05-12 - 0000 Lot No. CO
Site Plan Name: Ahl QS S hQd Block No. 15 3
Project Name:
DETAILED DESCRIPTION OF WORK:
IZ,c\(o u+�k�4 SMec1 tual-h P(MY} C'a-1
New Electrical Meter Second Electrical Meter.
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit- check all that apply:
_Mechanical _Gas Tank _Gas Piping _Shutters —Windows/Doors _Pond
V Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: 192 Sq. Ft. of First Floor: / 9 2
Cost of Construction: $ (00146.00 Utilities: —Sewer _Septic Building Height:
OW N ERAESSEE:
CONTRACTOR:
Name MonQh AHn-
Name: Mor(o-h Hb\u..S
Address:5(r)O5 Killca✓nQU GAM
Company: NACLLq-_OWr\Q4�
City: e± KP rr Q State: F9
Zip Code:31/951 Fax:
Phone No. -] 12 - 32 j - F� 7 SS
Address: 51(n65 Ki Ilrt ryVAa eke_
City: a. 1012422 Stater
Zip Code: 349 5 i Fax:
Phone No`I72-.323-!R7S5
E-Mail:n- Q9mic ant-nnil.ir,yc.edu
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
E-Mail Clblps m K O ino-i I. Ir5 C. ed u
State or County License
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
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SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: VC Not Applicable
MORTGAGE COMPANY: X Not Applicable
Name:
Name:
Address:
Address:
City: State:
City: State:
Zip: Phone
Zip: Phone:
FEE SIMPLE TITLE HOLDER: X Not Applicable
BONDING COMPANY: x 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 paying twice for
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie County and posted on the jobsite before the first inspection. If you intend to obtain financing, consult
with lender or an attorneybefore commencingwork or recordingour Notice of Commencement.
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Signature of Owner/ essee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA
COUNTY OF Sk. \-o�:�'¢-
COUNTYOF -9
Sworn to (or affirmed) and subscribed before me of
Sworn to (or affirmed) and subscribed before me of
_ Physical Presence or Online Notarization
this\\< dayof 2020 by
_ Physical Presence or Online Notarization
this_day of .2020 by
Name of person making statement.
Name of person making statement.
Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced L D L
Produced
(Signature
t_$1 'F* MY COPAMISSIONpOG 022023
Commission No. r 3EXPIRES: Dtt(+gWga416, 2020
.,,p3��o?•• Budded Tlw NotaryR i uodervrtiters
(Signature of Notary Public- State of Florida )
Commission No. (Seal)
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