HomeMy WebLinkAboutPERMIT APPLICATION 1 (4)SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: — Not Applicable
Name:
Address:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
City: State:
Zip: Phone:
City: State:
Zip: Phone
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name:
Address:
BONDING COMPANY: _Not Applicable
Name:
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 Owner/ Lessee/Contractor as Agent f r Owner
Signature of Contractor/License older
STATE OF FLORtPA
COUNTY OF LL,L it
STATE OF FLORIDA
COUNTY OF
The forgoing instr. ent was acknowledged efore me
this day of '' '_ 2(3`- Y
The fprrgoing instr ent was acknowledged before me
this . � day of J C(L, Zpw._by
Name of person ma g statement.
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification
Produced
Personally Known r OR Produced Identification
Type of Identification
Produced
,
1
(Signature otfi6faryPubli State of Florida
(Signature of Notar u lic- St t of Florida )
Co m S' "' "" KARLEY MARIE GIESYNARNEY
• fFlorida eal)
• CommissionOGG099801
rr mm. E% fires May 1, 2021
,•'•..OFf1 ,.' Bondedthrough NaM� allbtaryAssn.
REV I '�� G SUPERVISOR
COUNTER REVIEW REVIEW
Co '"' "' Q KARLEY MARIE GIESYNARNEY (Seal)
; • ° : rida
Commission N GG 099801
,.•, 11onded through Natio Mary Assn.
PL aI LE MANGROVE
REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.