HomeMy WebLinkAboutScan_0013SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION: I
Name:_
Address:
City:
Zip:
NGINEER: X Not Applica
Phone
State:
FEE SIMPLE TITLE HOLDER: Not Applicable
Name:
Address:
City:
Zip: Phone:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
City: State:
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 Fepresentation 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 lanrier nr an attarnev before commencing work or recording; vour Notice of Commencement.
da, V
Sig Lure of Contractor/License Holder
Signature of Owner/ Lessee/Contractor as Agent for Owner
STATE OF FLORIDA
�
STATE OF FLORIDA � ��
COUNTY OF `
COUNTY
Swor o (or affirmed) and subscribed before me of
Sworn t or affirmed) and subscribed before me of
Online Notarization
Physical Presenfe or Online Notarization
physical Prese ce or
day of d 2020 by
this day of Lt 2020 by
this
Name of person making statement.
Name of person makings ement.
Personally Known V OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
(Signature of Notary Public- State of Florida)
(Signature of Notary Public- State of Florida }
Commissio
Commission No�t!�yynr+
Notary Public Slate of Florida
State of FlosidaRitchie
REVIEW
My C,'omml
F OIRalres 1
56M
12 [6 11l
PERVISOR
PLANSIt.�l>ife
a �y� Co
VtUok
in GG i3
IS'F��RT
NGROVE
REVIEW
REVIEW
REVIEW
DATE
RECEIVED _
DATE
COMPLETED
Rev.5/b/ZU