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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: ch . 2L ZDZ-Permit Number: Z?LL01.pA -,Oq 73
Building. Permit Application
Planning and'DevelopmentServices /
Building and Code Regulation Division Commercial Residential 1/
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:V U S
PROPOSED IMPROVEMENT LOCATION: p
Address:
PropertyTax ID'#: - - I - Lot No_ f�
Site Plan Name: �LI IN, iA1_ ���le � __ Block No.
Project Name:
DETA1 LED .DESCRIPTION OF WORK:
New Electrical Meter Second Electrical Meter
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit- check all that apply:
Mechanical _ Gas Tank —Gas Piping Shutters
Electric —Plumbing _ Sprinklers _ Generator
Total.Sq. Ft of Construction: 1 L.P X T1
Cost of Construction: $ -3- SZ56
Sq. Ft. of First'Floor:
Windows/Doors .,,,` Pond
Roof Pitch
Utilities: _Sewer —Septic Building Height:
OWN'ER�LESSEE:
CONTRACTOR:
Name
A ' Z
Company: • Dt+
City: Yr -- L ucw- -Stater
Address: 3i%5'S I,"lLAL
Zip Code: MiA2WO Fax:
City: a> IWIAL,1 � _ Stater
Phone No.
Zip Code: b3w)4 Fax:
E-Mail:
Phone No 1^ q' 0)b
Fill in fee simple Title Holder on next page (if different
E-Mai U
from the Owner listed above)
State or County Licenser_
If value of construction is 2500 or more, a• RECORDED Notice of Commencement is required.
If value of HAVC is $7,50a or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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
BONDING COMPANY: Not Applicable
Name:
Address:
Name:
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 Homeowners 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 l 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,
accessary 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 an attorney before cornmenring wnrk nr rarnrdina vmir Nlntira of r'nmmonrpmant
1
Signature v wnerl Lessee/Contractar as Agent for Owner
Signatur Contractor/License Holder
STATE OF FLORIDAD
STATE OF FLORIQk
COUNTY OF_A AL IVN�eIA&A
COUNTY OF J3&-W-
Sworn to (or affirmed) and subscr' d before me of
Physical Presence Online Notarization
Sworn to (or affirmed) and subspribed before me of
or
Physical Presence or / Online Notarization
thi s_ day of -,S7_4» u L4 r2./ , 20,A[ by
th_1aR_I _ day OrZ9 / 2Q. L by
Mt Lt.t—
I t LL
Name of person making statement.
�-r-.AL,uAS
Name of person making statement.
Personally Known OR Produced Identification
Personally Known ✓ OR Produced identification
Type of Identification
Type of identification
Pr duce d
Produced
(Signature o Notary Public- Sta �j� a racy G 8cariatt
o Notary Public- 5tat Of � a )Notary Public State of FI
/_/� tea, EMy Commission GG 343fl
Commission No. (3(T 34 ✓O asFd�seai`���e50610912p23
ligLure
B Tracy L Scarlott
5�1��mission GCs 343
ission ND � '�1",
rea 0610812023
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FRONT
ZONING
SUPERVISOR
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DATE
COMPLETED
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