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SUPPLEMENTAL CONSTRUCTION LIEN LAW
DESIGNER/ENGINEER: _Not Applicable
Name:SUMI T TOEsK:H s FORENs$cs INC
Add ress 725 se PORT ST Ducie BLw
City' PORT s, LUcE State: FL
Zip: 34984 P h o n e n,2.2s5. o572
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FEE SIMPLE TITLEHOLDER. _Not Applicable
vame:
Address:
City:
Zip: Phone,.
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INFORMATION0
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MORTGAGE COMPANY0
, _Not Applicable
Name;
Address:
City: State:
Zip: Phone:
BONDING COMPANY:
Name:
Address;
city:
Zip; mw� Phone:
Not Applicable
OWNER/ CONTRACTOR AFFIDVITs. Application is hereby made to obtain a permit to do the work and installation as indicated.
1 certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County mikes no representativr� that is granting a permit will authorize the permit holder to build the subj�e+�t structure
►n►hich is in �onfli�t vuitF� 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 dor any restrictions which may apply.
In canstderativn of the granting of this requested permit., I do hereby agree that I wilt, in ail respects, perform the work
in accordance with the approved plans, the Florida Buflding fades and St. Lucie County Amendments.
the following building permit applications are
exempt from undergoing a full
concurrency review: roam
additions,
accessory structures, swimming pools, fences,
wall, signs, screen rooms and
accessory uses to another
non-residential use
WARNING TO OWNER: Your failure to Record a Notice of Commencement may result :n paying twice for
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mprovements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie Cound posted on the jobsite before the first inspection. If Yov intend to obtain financing, consult
with lenderrr n attorney Wore compiOi?cing work or recording vou^otice of Com ncement.
stgnatunevof Owner/ Lessee/Contractor as Agent for owner
STATE OF FLORIDA
COUNTY OF
&V
Syyorn to (or affirmed) and subscri
Physical Presence or
this day of
'17n. 7%'
bed before me of
)nhne Notarization
2020 by
Name of person making statement.
Personally Known OR Produced Identification
Type of Iden fetationProduced
Al 4WP -A
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(Signature of No ari Public.. State of Florida
C o m mi ss i o n N o ;PC>(C> I
REVIEWS
DATE
RECEIVED
DATE
COMPLETED
ev. 51612u
FRONT
COUNTER
oe
Signature at Contractor/Licen-se Holder
STATE OF FLORIDA
COUNTY OF
I%&ONVOW
Sworn to (or affirmed] and subscribed before me of
Physical Presen or Online Notarization
this day of 2020 by
14o 1,
Name of person making stat
Personalty Known I
Type of Identification
y
mop
/0110/
iit.
OR Produced Identification
SHIRLEYr
SAUNIE1 I
G CSeaAlry pubjj17 o State of Od#n
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