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SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION
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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 1 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.
Signatur of Owner/Lessee/Contractor as Agent for Owner SignatVKe of Contractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA '
COUNTY OF ` COUNTY OF l .C\
The forgoing instrum t was acknowledged efore me The f oing instru t was acknowledge efore me
this�ay of 20 �y this y of��- .20 by
be
(Name of person acknowledging) (Name of person acknowledging)
a'�", L' tr\ a , a,
(Signature of No Public-State of FI rida) (Signature of Nota Public-State of Florida)
Persona 4,,,sR GR1Brbd0it8dFfid i i ti Persona y Kr�puvat,�t �rpd IcJenY on V
Type of �e►3 P(dddclt@�lic-State of F lksni.
Type of * ¢{�FKWWRAlic- to oriel
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n •_ Commission# FF 234730 _.; ;•_ Commission# FF 234730
Commis'lio P' My Comm.Expires May(ge Commis - .oQ: My Comm.Expires May 2fr�y
OF Bonded through National Notary °;,`„•`' Bonded through National Not ary Assn ;a
Revised 07/15/2014
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REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
COMPLETE
INITIALS