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All APPLICABL INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: 2 020�L 1 Permit Number:
�Vo [LUC E'1� RECEIVED
FEB - 3 2021
Building Permit Application
Planning and Development Services Permitting Departm t
Building and Code Regulation Division Commercial Residential Lucie C°u"
2300 Virginia �A venue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR: W,\� 6\
Address:
Property Tax ID #: D?-� ��(���)-►d�/�� Lot No.
Site Plan Name: Block No.
Project Name:
New Electrical Meter
Second Electrical Meter
Additional work to be performed under this permit- check all that apply:
_Mechanical _ Gas Tank _ Gas Piping _ Shutters
_ Electric _ Plumbing _ Sprinklers _ Generator
Windows/Doors _ Pond
Total Sq. Ft of Construction: Sq. Ft...of First Floor:
Cost of Construction: $�� Utilities: —Sewer —Septic
Roof . Pitch
Building Height:
OWNER/LE=�SSEE:
CONTRACTOR:
Name
Name:-- .
Company: '
Address: (,l CQ r
City: State: i,-
Address:
Zip Code: 6q$� Fax:
City: State:
Phone Nc( r010,si
Zip Code: Fax:
E-Mail: 1,10e. (601
Phone No
Fill in fee simple Title Holder on next page (if different
E-Mail
State or County License
from the Owner listed above)
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.
FM
UPP EME AN. Ca �, T NT11 t W
FOR+ Ti N•
DESIGNER ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
Address:
City: State:
Zip: Phone
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name:
BONDING COMPANY: Not Applicable
Name:
Address:
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 paying twice for
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie Couy an posted on the jobsite before the first inspection. If you intend to obtain financing, consult
with lend r o attorney before commencing work or recording your Notice of Commencement.
Signature of ner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA
COUNTY OF .y . L1)c"L
COUNTY OF
Sworn to (or affirmed) and subscribed before me of
Sworn to (or affirmed) and subscribed before me of
sical Pres nce or Online Notarization
Physical Presence or Online Notarization
thisday of2 by
A
this day of 2020 by
>�.
i
Name of person making statement.
Name of person making statement.
/
Personally Known OR Produced Identification "'
Personally Known OR Produced Identification
Type of Identificatio L
Type of Identification
Produced
Produced
e1�
(Signature of Not
(Signature of Notary Public- State of Florida )
KAREN S. NIELSEN
Commission No.
,�YP�a
,�o =_° ` _State of Florida -(Notary Public
EG 207484
Commission No. (Seal)
- mmissi
My Commission Expires
�j�OFf
`p`��
June 12 2022
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ev. 5/6/20