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Date: Permit Number:
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P!annLnq and Development Se-rWres
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2300 Virginia Avenue, Fort Pierce FL 34982
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PERMIT APPLICATION FOR:
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Address:
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Site Plan Name: -2(2 Block No.
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—Mechanical Gas Tank Gas Piping Shutters Wind S/Doors Pond
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Total Sq. Ft of Construction: Sq. Ft. of First Floor: SOO :5r mo
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11 Name I U2j4 I Name:w6ll6Qu
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Z - &I City: (1-f Qa 60 Irc State: Address: MO VAS� Wj&>4t3!?�j
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IF;�_U Phone NO.A?z 97 Ut2 -_ — Fax; 772 elV yelf
E-Mail: Phone No -712- A-Ie-1677_33
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from the Owner listed above) 2e 06,6,6 Z!;-
State or County License
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if value of HAVC is$7,500 or more,a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY:
Not Applicable
Andress:
City: State: City: State:
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rFEE SIMPLE TITLE HOLDER: Not Applicable BONDING COMPANY: /Not Applicable
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OWNER/CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
1 rertify that no work or installation has commenced prior to the;issuance of a permit.
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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.
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The following building permit applications are exempt from undergoing a full concurrency review:room additions,
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VVAKNINU I U till NI:K: Your tanure to Kecord a Notice of Lommencement may resuit in paying twice Tor
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
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th e 1 o b'r itt a- before-11 e first inspectlion. Iff you i r iten-j to n ricincy. consult
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1akur_e c" nerf Lessee/Contractor as Agent for Owner 4ign_a-tbT6of ttnti7�a_Mr/License H6!de-r --
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Sv,,qrn to for affirmead!and Subscribed be-' re me of Sw.,orn ta!nr affirmed'and before me of
this day of 2020 by this day of 2020 by
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Produced Produced
(SignatLire of Notary Public-State of Florida (Signature of Notary�pOlic-State IN...... Comm I&JR
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ERIN R.MILLER,,pi If Isslon
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C(immigslon#GG 28165# Aires Februaii��ki2
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OF fvif 8"40d Thm BudgM Nobq Smk"Pg Expires February 3,2022
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