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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED(0�
Date: Permit Number-: 2,0/01
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Building Permit App ication
Planning and Development Services
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. -
Property Tax ID #:
Site Plan Name:
Project Name: _
New Electrical Meter Second Electrical Meter
Lot No.
Block No.
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, Q Sq. Ft. of First Floor:
Cos-adf.,Go uction: $ - (� (�� , Utilities: _ Sewer _ Septic Building Height: _
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CONTRACTOR'
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Name 5 A e n W 7)
Name:
Address: a-- //).,-
Company:
City: State:.
Address:
City: State
Zip,Code: Fax:
Zip Code: ? Cj el Fax:
Phone No.
E-Mail: rTfN �� r`4/ + lit, Lf E1ame; Cem
Phone No
Fill in fee TitleeHolder
simple on next page (if different
E-Mail
from the Owner listed above)
State or County License
.... „ ,,,�,c, d ��. WrUJrU KMuuce of t-ummencement is requires.
If value of HAVC is $7,500, or more, a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER: — Not App i
Name:
Address:
City State:
Zip: Phone
FEE SIMPLE TITLE HOLDER: — Not Applicable
Name:
Address:
City:
Zip: Phone:
MORTGAGE COMPANY: Not Applicable
Name;
Address:
City:
Zip; Phone:_
BONDING COMPANY:
Name:
Address:
City:
Zip: Phone:
State:
Not Applicable
made to obtain a permit to do the work and installation as indicated.
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby
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 structuf,,e.
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit'
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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 aY before commencing work or recording your Notice of Commencement.
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gnature of Owner/ Lessee/Contractor as Agent for Owner rzy Signature of Contractor/License Ho
STATE OF FLORIDA 'S STATE OF FLORIDA
COUNTY OF ,L
t o - COUNTY OF
Sworn to (or affirmed) and subscribed,before me of Sworn to (or affirmed) and subscribed before me of
Physical Pre a or Online Notarization Physical Presence or Online Notarization
this7� da f
2020 by this day of 2020 by
Name of person making statement.
Name of person making statement.
orally Known OR Produced Identification
of Identification
uced
State of Florida
Commission No.
REVIEWS I FRONT
COUNTER
DATE
RECEIVED
DATE —
COMPLETED
Personally Known OR Produced Identification
Type of Identification
Produced
(Signature of Notary Public --State of Florida )
(Seal) Commission No. (Seal)
ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
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