HomeMy WebLinkAboutchaska stALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
s
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: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMWT LOCATION:
Address: ,
Legal Description:
Property Tax ID #: 0 — Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION OF WORK:
D,t� (UAA) W hoa&_
CONSTRUCTION INFORMATION:
Additional work to e er orme under this permit —check a apply:
HVAC OGas Tank ❑Gas Piping Shutters ❑ Windows/Doors
❑Electric L_JPlumbing ❑Sprinklers ❑Generator ❑Roof Roof pitch
Total 5q. Ft of Construction:
Cost of Construction: $ 12 DO
S Ft. of First Floor: _
Utilitiest Sewer ❑ Septic
Building Height:
OWNERAESSEE:
CONTRACTOR:
Name
Name:
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�y
Address: �5Id JAI"",
Company: ?
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jj
City: State 1
Zip Code: Fax:
Phone No. %
Addr
ilk.
City:
Zip Code:
Phone No. %
`Pi State: FJ
Fax:' � � 'S �►
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E-Mail:
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
E-Mail: J '
a L
State or County License:
It value of construction is 52500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY: Not Applicable
Name:
Address:
Address:
City: State:
City: State:
Zip: Phone
Zip: Phone:
FEE SIMPLE TITLE HOLDER: Not Applicable
Name:
BONDING COMPANY: Not Applicable
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 bylaws
rules, 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.
Signature of Owner/ Lessee/C o as Agen or Owner
Sign a u ontractor/License H
STATE OF FLO A
COUNTYOF '�'� ,(,�i�C. _
STATE OF FLORIDA
COUNTY OF
The forgoing instrjuperr�was acknowledged before me
this ( day of 20b
�r
The forgoing instr�n was acknowledge�j before me
this day of 20 by
C`
a of person making atement
Personally Know OR Produced Identification
son making sta ement
Personally Known OR Produced Identification
T e of Iden
Type o cation
Prod ed
Prod ed
k— 011ot
a
Signature of
�g!!. F "' LiBEItiY A.rod
- H4YCOMMESSto" 3i
Commission ;.: <: `q
ES: may ,
7TM N0 Public Uiwienrrilees
ignature of Nota c- State of Flori )
H1,„
.•'' � : '' LIB �ING
Commission No. 1
.. y cvmmll GG ( M63a
'�9 ¢ `8 EXPIRES: May 4, 2021
Son W Thru Notary Public Ltmenvok s
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEA TURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 8/2/17