HomeMy WebLinkAboutBUILDING PERMIT APPAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: l 2 Permit Number:
V. L CM C U Ey
V U
Building Permit Application
Planning and Development Services
Building and Code Regulation Division Commercial Residential `u
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 452-1578
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Address:
Property Tax ID #:} UI lU - .�U� ~ �� ( 3
��� _� Lot Nv-f,7�_,--
Site Plan name: Block No. D
Project Name:
DETAILED DESCRIPTION OF WORK:
I T f-I Y
New Electrical Meter Second Electrical Meter
[CONSTRUCTION INFORMATION:
Additional work to he 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:
Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —Sewer , Septic Building Height:
OWNERAESSEE:
CONTRACTOR:
Name I-- - CMLS
iVarrae:
Address:'55�iG
Company -
City fza Qw a State:
ss
Addr '5,
Zip Code:�j 2- Fax:
City:
State
Phone No. - L
Zip Coder
E-Mail:
Phone No` L
Fill in fee simple Title Holder on next page ( if different
E-Mail cI
,
from the Owner listed above)
State aunty License(�l
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: , No# 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:
Add ress: Address:
City: City:
Zi p: 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 Nome 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 }obsite before the first inspection. If you intend to obtain financing, consult
with lender or an attorney before commencingwork or recording your Notice of Commencement.
Signature of Owner/ Lessee/ actor�Ag n:f-or Owner Sign Lure of Contract r/License Ho der
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF COUNTY OF
Sworn to for affirmed} and subscribed before me of Sworn to for affirmed) and subscribed before me of
Physical Presence or Online Notarization Physical Presence or Online Notarization
this day of 2t72�! by this day of 202 by
V1 v 1
Name of person making statement. Name of person making statement.
Personally Known OR Produced Identification
Type of dentifica
Prad d
71t1re of N Lyubli
+ � Notary Pubft Stale of pWkia
Commission No.
K Cook
GG 349A&2
,k,�: Expires 0et27reM
REVIEWS I FRONT ZONING
COUNTER REVIEW
DATE
RECEIVED
DATE
COMPLETED
Personally Known t-t-� OR Produced Identification
Type of Identification
of Not r� 5
y _ Natarp Public State of Ronda
1 No.� �f li � K'RC� WYt@r9 Cook GG 348482
110 a) Expir®s 0&2712623
SUPERVISOR I PLANS I VEGETATION 1 S REVIEW TURTLE I MANGROVE
REVIEW REVIEW REVIEW+EW
PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR, SUBCONTRACTOR OR CANCELLATION OF PERM
PLEASE SELECT ONE OF THE FOLLOWING:
-43 CHANGE OF CONTRACTOR — Change of Contractor is to be signed and notarized by the property owner,
and the new contractor of record for the current permit_ A new permit application must also be completed with new
contractor information and signature. A new Notice of Commencement must be filed in the new contractor's name
for job values greater than $2,500 ($7,500 if A/C Change -out). A recorded copy must be submitted prior to
commencing any work. There is a $50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR — Subcontractor changes are to be completed by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. There is a $50.00 fee for the Change of Sub -
Contractor.
CANCELLATION OF PERMIT — The cancellation of a permit is acceptable only if no work has been dome.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Bate: 2, Permit Number:
Site Address:
State License_
Original GC, subcontractor ar owner/builder
SLC License
9 0— C State License J LC License
New GC, subcontractor
Reason for Cancellation
The undersigned does hereby agree to 7nderrtnify and hold harmless St Lucie County, its officers, agents and employees from ail
costs, fees or damages arising from any and all claims of action for any reason, which may arise as a result of this change of
contractor/subcontractor or cancellation of permit. A permit cannot be cancelled if work has been performed.
9IGNATUE OF OWNER (or ownerlbuilder)
PRINT NAKE ��� �� t
State of Florida, County of St. Lucie County
The following insminient was aolatowledged before me this
day of Rn 203L, by
Ito is ovally lm me
or wt1 prod*e . as 11).
Date
Revised D4115/16
SCF��TUkff ENERAL e6WRACTOR for new GC, as applicable)
PAINT ]NAME
State of Florida, County of St. Lucie County
TNP llowing ent was aclmowk4,ed before me this
dayof J 02A, bY. ()0
who 's pecsottallykna to
1114❑figs produced _ ss71i],
ignatare of Notary %pA