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SU:PPLEMENTALCONSTRUCT ION LIEN LAW INFORMATION
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:
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 JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT."
Signature of Ow r/Lessee/Contr or as Agent for Owner Signature of Contractor/License-Holder
STATE OF FLORID' STATE OF FLORIDA 0 -rS G_, /E
COUNTY OF �, 7 �// GUG�IC COUNTY OF
The fo going instru ent was acknowledge] before me The forgoing instrument was acknowledged before me
this a day of r 20_ by thisa/ day of &;'V66X 120 90 by
611MYL 61ta- or �y15_M&A _5
Name of person making statement. Name of person making statement.
Personal n Z)V Produce Identification Personall wn K Produ ed Identification
Type Identifi ati n Typepf denti (cation
Pr_duced Pr �fuced
(Signa re of Nota _ribR a ef`Ftorr ar
(Signs ure of/Noary Publ' -State„Qf F�1ori�{
•S�py pV••,,, JOHN MICHA LFERRICK ,. RV PUe(,; J0� MICHAEL FERRCK
NotaryPub�ic-State ofFlarida ;r, Notary Public-State of Florida
Co mission No * Commis 294120418 Co mission N _•+ •_ Co l)#GG 720418
My Comm.Expires Aug 26,2021 z oP5 My Comm.Expires Aug 26,2021
Bonded through National NotaryAssn.
Bonded through National NotaryAssn.
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW"—
DATE
' RECEIVED
DATE
COMPLETED
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