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ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
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Date: Permit Number: ��
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Bu ding Permit Application
Planning and DevelopmentSery
ivce FL
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Building and Code Regulation Dision
2300 Virginia Avenue,Fort Pier 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
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Legal Description:__/-�A/1�011� JQl�6E �LAT� ,QD�/qL Get./ V6GC�GE UPI% aj
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Property Tax ID#: o15-
- (a0S• 0.'Z3—Q OQ Lot No.
Site Plan Name: Block No.
Project Name: QPZ Ae�5L CC
Setbacks Front Back: Right Side: ESN eft Side:_5 .
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itiona wor to e e orme un er t is permit—c ec a app y:
�HVAC �Gas Tank ❑Gas Piping _Shutters a Windows/Doors
Electric Plumbing Sprinklers Generator Roof Roof pitch
Total Sq. Ft of Construction: S . Ft.of First Floor:
Cost of Construction:$ ��,��� , _ Utilities:cn Sewer O Septic Building Height:
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Name ll_c�2 X f��lncc �� Name: i f
Address;�0/� /1�(1J �c,( �z�t/7Cj• A Company: E C
City: )P" State: C Address: jo
Zip Code: Fax: City:� State:
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Phone No. 7-1--Y/9 -S(S1 Zip Code�41301` Fax:
E-Mail: - e_6� Phone ` - -912
Fill in fee simple Title Holder on next page(if different E-Mail: tic
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from the Owner listed above) State or County License:
If value of construction is$25001or more,a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone:. Zip: Phone:
FEE SIMPLE TITLE HOLDER: _Not Applicable BONDING COMPANY: Not Applicable
Name: Name:
Address: Address:
City: City:
Zip: Phone: Zip: Phone:
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
commencing work or recording our Notice of Commencement.
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gna re of Ow er/Lessee/Contractor as Agent for Owner Signature of Cont c r/License Holder
STATE OF FLORI A STATE OF.FLOXqA
COUNTY OF COUNTY OF { 169-A A
The for ng instru ent was acknowledged before me The fo going instrument was acknowledged before me
this day of .J f{(�1 20 h by this may of 20 by
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(Name of person acknowledging) (Name of p on ark owledging)
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(Signature of Notary b c-State lorida) (Signature of Notary Public-State of Florida)
Personally Kn g (gkRntifica n Personally Known, OR Produced Identification
Type of Identi 3 21 r gdur pJ0FF928213 Type of Identification Produced
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EXPIRES:January 3,2
Commission N `'%'••••o�,' Bonded lhru Notary P°br "d° dt�� Commission No ° BEv Ath'
MY COMMISSION#GG 00063 I s
EXPIRES:July 6,2020 r
'•,°�;;,: Thru Notary Public UrAeenwiters !
Revised 07/15/2014
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER. REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
COMPLETE I 2JO i n ;� }
INITIALS ✓ f�