HomeMy WebLinkAboutPg. 2 - Dickinson AveSUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER:
Name:
Address:
Not Applicable
MORTGAGE COMPANY: Not Applicable
Name:
Address:
City: State:
Zip: Phone:
City: State:
Zip: Phone
FEE SIMPLE TITLE HOLDER:
Name:
Not Applicable
BONDING COMPANY: Not Applicable
Name:
Address:
City:
Zip: Phone:
Address:
City:
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 Ike recorded in the public records of St.
Lucie County and pasted on the jobsite before the first inspection. If you intend to obtain financing, consult
with lender or an attornev before commencing work or recording vour Notice of Commencement.
�LLI'� ��i LJI�2
Signature of Owner/ Lessee/Cbntractor as Agent for Owner Signature of Contra ctor/Licens4 Holder
STATE OF FLORIDA _� STATE OF FLORIDA _r
COUNTY OF �iyy�eyy iyGd _ _ COUNTY OF .ji., l2.ir
Swor to (or affirmed) and subscribed before me of
Physical Presence or Online Notarization
this -21 day of r iqv,4 J 202t by
Name of person making statement.
Personally Known V/ OR Produced Identification
Type of Identification L ��
Produced
I/z�ft202,1
Swor to for affirmed) and subscribed before me of
Physical Presence or Online Notarization
this '22- day of v; u! 2024 by
Name of person making statement.
Personally Known V OR Produced Identification
Type of Identification
Produ-ced rt.
(9ignatu)-61A Notary Public- Sta
mature df Notary Public- State of
oii>iY'•i NWA9ATA EPHRAIM
1 l �51-} r ' �: Na ry Pubic - State of Fiori
Commission No. VA �/ _���4. Seal)Commission M HH 550
'yk
a r
mmission No.
off:
My Comm. Expires Aug 25, 2024
Sanded through 43tjaral KotaNotaq.Arg
n
REVIEWS
FRONT ZONING
SUPERVISOR
PLANS
VEGETATION
SEATURTLE
COUNTER REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
NwABATA EPHPU
�= Notary Public - State s
IcyCCommission ii HH
omm. Expires Aug
Bonded through National No
MANGROVE
REVIEW