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ALLAPRJCABLEINFO MUST B50DMRET®FORAPPLICATION-TO BEACCIPTID
Date: `�1 �� Fbrmit Number:RECEI I1 d�rG
' l Y"a7
Building Permit Application
Ranning and Development Services
Building and Cbde Regulation Division
2300 Virginia Avenue,Fort Rerce R -34982
Phone:(772)462-1553 Fax: (772)462-1518 (bmmerde l Fbsidential
PERM ITAFFUCAMON FOR To Select from dropbox, click arrow at the end of line
PFOPOM)IM PROVRA ENT LOCATON:
Address: v�
Legal Description: "L 1-u-s -nit- /.A s
PropertyTax ID#. Lot No.
Ste Ran Name: Block No.
Project Name:
Setbacks Front Back: Fight 9de: Left 9de:
DECAIL13D DM9PflON'OF WORK
F06NsTgiCTION INFORMATION:
Additional wor o flGasTank
orm un er is perms - apply:
0 HVTI
AC Gas Rpi ng _9iutters a Windows)Doors
11 Bectric ❑Plumbing �rinklers 1 Generator E bof Roof pitch
Total Sq. R of Construction: 81. R.of First Floor:
Cost of Construction:$ "I 'U 9 .pO Utilities Sewer EI Septic Building Height:
OWNS/LF OONTPACTOR
Name , Name: �Ikw
Address:I Rao 4 C-g 'ayc. Company: q Qr'
Clt .se _o : ate�r 1 Address:5 ( ns�-I~ �20
Zip 0Ade3Lk AS°'1 Fax City-- g-� Mate�
Phone No._`)'1a-c�LQI% -414`ltA 2ipCode5�k ;- W
E-Mail: Phone No. 4
Fill in fee simple Title Holder on next page(if different E-Mail:
from the Owner listed above) :fate or Cbunty License:ST->-,Q�3 Cpb
If value of construction is$2500 or more,a FORD®Notice of(bmmencement is required.
Now
JPPLBVI6VTALOONSTF .JCT10N UBV1AW INFOFMA-flO
DESIGNER ENGINEER —Not Applicable MORTGAGEQOMPANY: _Not Applicable
Name:sSte-kLQ— U)cxm_y Name:
Address: ,)o 5(_ i n Tj`i v-A_ Address:
City: .Piy_.r0 _P _ Stater-1 City: Mate:
Ap3QCIS 2 Phone: 440-14 Zlp: Phone:
FEESIMPLETTTLEHOLDER Not Applicable BONDING OOMPANY: Not Applicable
Name: Name:
Address: Address:
City: CRY:
Zlp: Phone: Zip: Phone:
I certify that no work or installation has commenced prior to the issuance of a permit.
g.Lude County makesno representation that isgranting apermit will authorizethe permit holder to build the subject structure
which is in conflict with any applicable Home OwnersAssocaation rules,bylaws or and eovenantsthat may restrict or prohibit such
structure.Pease 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 Rorida Building Codes and g.Lude C.buntyAmendments
The following building permit applications are exempt from undergoing a full eoncurrency review:room additions,
accessory structures,swimming pools,fences,walls,signs,screen rooms and accessory usesto 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 or recording our Notice of Cbmmeneem
s
9gnature of Owner/Lessee/Cbntractor asAgent for Owner Signature of(bntractor/License Holder
STATE OF (
OOUNTY ORJORI DA cS �` OOUNTY OFSTATE OF ORI D /_ cl
Thef in ent was admowledged before me The f gym,g instrument was admo edged before me
this day oft �l � 20 �"tiy this ' dby of 1"r"4 CC✓ 20y
C
(Name of person ackno g (Name of person adm ging)
(9gnature of Notary Public gate of Rorida) (Signature of Notary Public-gate of orida)
Pi;rsonally Known ORProduce4J&ntification Personally Known ORProducad I entification
Type of Identification Produced 1209
entification Produced
Commission No. a L Z - ,,a�," ) UNA URIOLon No. �� ���"' URIOL
97
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Notary Public'State + • '•,
: Notary Publl -State oI LI®Fi9i
•''- Commission OFF,
JCommission rY FF 921®111Sep
My.Comm. ; My .omm.
Revised 07/15/2014 •''F°`"
RBABNS FRONT ZDNIIG SJPEVISOR PLANS V133EM IO N (FATURTLE MANGROVE
00UNTER REMBN FEVIBN FUAEW FEMBN REMBN REMBN
DATE
INITIALS