HomeMy WebLinkAboutPERMIT APPLICATIONALL APPLICABL INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: < /; Permit Number:
Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
PERMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT LOCATION:
Address:
Legal Description: b) u a )nd A Pi 'y) Q ,Q ►b' 1
Property Tax ID #: 3q 1 S' -1 Q ( o' 00 4 t ` 000 ' � Lot No. �
Site Plan Name: Block No. "
Project Name: \'Y� \ ``-. ML
Setbacks Front Back: Right ide: Left Side:
DETAILED DESCRIPTION OF WORK:
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit -check a apply:
nHVAC Gas Tank ❑Gas Piping _Shutters Q Windows/Doors
FlElectric I �J Plumbing Sprinklers [i Generator F Roof Roof pitch
Total Sq. Ft of Construction:
Cost of Construction: $ I ;
S Ft. of First Floor:
Utilities:cnSewer Septic Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name Y f
Name: 1
Address: I
Company: I '
City:�fp* St t •
Address:
Zip Cod • Fax:
Cit Stat
4l'
Phone No.'-1 `1 ,_A q 1 ( q (o`7
Zip Code: '�?Fax:
E-Mail:
Phone No. `7 `]
E-Mail: ,
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
State or County License: (20_0 _171'
it vdlue yr construction is :�/_5uu or more, a KtcUJIMU Notice of commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAWN INFORMATION:
DESIGNER/ENGINEER: ` Not Applica
Name:
Address:
City: State:
Zip: Phone
FEE SIMPLE TITLE HOLDER: — Not Applicable
Name:
Address:
City:
Zip: Phone:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
City: State:
Zip: Phone:
BONDING COMPANY: Not Applicable
Name:_
Address:
City:
Zip:
Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to ao the worK anu 1111LdIrd LIVII dJ IUI._QLCU.
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
�... &ory nrrnnsr nnnnnnawsc vnM ID NnTli F nF CnMMENCEMENT."
in I H 1 VUK LCMDER vim AN A ■ ■ %psys- ■ ua.■ v■a.. ■�.-vv.....•��•
• .�—__ .__ _
Signature of Owner/ Lessee/Contractor as Agent Y Owner
Signature of Contractor/License older
STATE OF FLO Ht�*D�►
STATE OF FLOR(I�A
b
COUNTY OF m�3r 1A CI_-1
COUNTY OF
The forgoing instrument wa! acknowledged before me
The forgoing instrume was acknowledged before me
2�by
�- day
�"
this 3 _day of i' 20 by
this` of t _
Name of person making statement.
Name of person making statement.
/
Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
f1 A Of) I A Qi n L A /A A11D1Y)
jerkkt � I A �t _-VA VIV
(Signature of ary Publi State of Florida
(Signature of Notal7 u lic- St t of Florida )
Corn 5 KARLEY MARIE GIESY VARNEY
eal)
KARLEY MARIE GIESY•VARNEY (Seal)
CO 0•Now rida f }
* • = COmmissl;, # GG OM01
•
. ° • `_ Commission # GG 049801
r= mm.Ex iresMay1,202t
t:
BandaditirgsghNa' to
�i"14U11T"
IWaryksn.
G
SUPERVISOR
PL
„•' IondedthrouoNatio
Notary Assn.
LE
MANGROVE
REVI
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 2/7/19