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ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED I C2 OL 25D
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Building Permit Application %60
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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
Address: '`NLe>-66
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Property Tax IDq: P5 (pa000 I 000'i� rJyaOO
Lot No.
Site Plan Name:
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Block No.
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Project Name: U. J Di l T
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Setbacks Front Back: Right Side: Left Side:
`D TAlI ED DE5 R PTION O WORK: a' Wo
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IC•O;N;SITRLN 1NF.QRMAtTiION:
itiona wor to e errormed under tispermit-check all
EjHVAC Gas Tank Gas Piping
Electric � Plumbing ❑Sprinklers
Total Sq. Ft of Construction: ScFt.
Cost of Construction: $ 53235. QQ Utilities.,
apply:
_ Shutters ❑ Windows/Doors
ElGenerator D Roof Roof pitch
of First Floor:
Sewer Septic Building Height:
�^OWNER�LrESSEE:
CONTRACTC+Re
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Name (..:QI ✓
Address: &� WIl�CG} CO1 VC 1`�L
Name: e 'Zrq HCAQ
Company: CA Qe Gne
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City: �1 'C State:
Zip Code:3�,L4 R����111�1 Fax:
Phone No.�55 -4DQ5'3
Address: Rile —
City: FT Pi2_Mer
Zip Code: 3_(95sa Fax: -710LfW-
Phone No.'i_i (o O (p(o
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E-Mail:
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
E-Mail:
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State or County License: C,Vt�),rj Vo 3,
If value of construction is $2500 or more, a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER:
Name:
Not Applicable
MORTGAGE COMPANY:
Name:
Not Applicable
Address:
Address:
City:
Zip:
Phone
State:
City:
Zip: Phone:
State:
FEE SIMPLE TITLE HOLDER:
Name:
Not Applicable
BONDING COMPANY:
Name:
_Not Applicable
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 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
commencingwork or recordingour Notice of Commencement.
Rev. 8/2/17 14-
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Signature of Contracto ense Holder
Signature of Owner/ Les ontractor as Agent for Owner
STATE OF FLORIDA
STATE OF FLORIDA
COUNTY OF �- Luo.2
COUNTY OF�V L�xca 2.
The forgoing instrument was acknowledged before me
The forgoing instrument was acknowledged before me
thism��d\ay_of C1ov'e7rv.�o2! 120ft by
thiso��d�aypQf (\1C—�1J2�rn�pEl20� by
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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
Produced
�OiLr6 .A.FiL�L
(Signature o Notary tary Public- Sate of Florida)
Sign ure of N ary Public- State o Florida )
Commission No. PublioState ofFlori
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an Sarah BIyStOne
C mission No. .�12
Public State
MY Canmieaion GG 381285
�i Expires 08124I2023
of Flaritl
Marie Sarah BIl9tOn0
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mluion GG 361295
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