HomeMy WebLinkAboutDocScan POTTER APPLICATIONAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date:�[� Permit Number:
§Vo [LUCE
Building Permit Application
Planning and Development Services w,.
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Address: p
((��--,,(� � �•
Property Tax I D #:t' af, "� Lot N o.
Site Plan Name: (O_C"C \_ ko \ ' Block No.
Project Name: r �`
DETAILED DESCRIPTION OF WORK:
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New Electrical Meter Second Electrical Meter.
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit —check all that apply:
_Mechanical _ Gas Tank —Gas Piping — Shutters Windows/Doors _ Pond
Electric _ Plumbing —Sprinklers —Generator — Roof Pitch
Total Sq. Ft of Construction:
Cost of Construction: $'S
OWNER/LESSEE:
Sq. Ft. of First Floor:
Utilities: _ Sewer _ Septic Building Height:
NameNN\ 11 a
Address 9&Q N_� 2� �& '�
City: � � I IC lic) - — _ State:
Zip Code: _ Fax
Phone No —
E-Mails[ _ l
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
CONTRACTOR'' ��:
Name:,1�JU
Company:
Address i ��-- �f
City: �' _C State:._EL_
Zip Code: Fax:
Phone No 1` � � M
E-Mail hi &Ay ccLACLIC5 _QN
State or County License
if value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION 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 paying twice for
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie County 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 your Notice of Commencement.
Signature of Owner/lessee/Contractor as Agent for Owner Signature of Contractor/License Holder
STATE OF FLORIDA STATE OF FLO IDA
COUNTY OF Ma(k) n ___I COUNTY OF rT df-
Sw�•to (or affirmed) and subscribed before me of
V Physical Presence or Online Notarization
this day of 2020 by
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification
At ANDA UBOIS
��'• :*= tutiY i;OMFAISSIOtV #GG 174804
rkit, 8: Anni 22, 2:1
(Signature of Notary P
Commission NoG'el1-7 kJ (Seal)
REVIEWS I FRONT I ZONING
COUNTER REVIEW
DATE
RECEIVED
DATE
COMPLETED
Sworn o (or affirmed) and subscribed before me of
Physical Presence or Online Notarization
this J&day of r 2020 by
Name of Orlon making statement.
Personally Known ✓ OR Produced Identification
Type of Identification
Produced
Y I / My COMMIsSjojV # QG 17�
(Signature of Nay Public -
Commission No
SUPERVISOR I PLANS VEGETATION I SEATURTLE
REVIEW REVIEW REVIEW 4 REVIEW
Th, u Notary Public
MANGROVE
REVIEW