HomeMy WebLinkAboutPERMIT APPLICATION DOCSAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34382
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
Address: �4
Legal Description: ►
Property Tax ID #: 64 1 LA
Site Plan Name: Ph-LxQ_
Project Name: (� Y
Setbacks Front Back:
Building Permit Application
Commercial Residential
Right Side: Left Side:
Aaanionai work o be pertormed under t is permit — c ec . all that apply:
_Mechanical _ Gas Tank —Gas Piping , Shutters
— Electric _ Plumbing _ Sprinklers Generator
Total Sq. Ft of Construction:
Cost of Construction: $ Q `-1" (j (:)
Sq. Ft. of First Floor: _
Utilities: —Sewer —Septic
Lot No. k i
Block No.
_ Windows/Doors
Roof Pitch
Building Height:
Name
Name:
Addre . i(`
Company:
'
City: ibil Sta
Address:
Zip Code; -I_ Fax:
Ci
St
Phone No.
Zip Code'
Fax:
E-Mail:
Phone No
Fill in fee simple Title Holder on next page ( if different
E-Mail )
J %
from the Owner listed above)
State or County License` (o
- I -- Mu. w.. t�Ww %J1 111%P1o. ti ncwnWw VALKICe or t.ommencement is required.
SUPPLEMENTAL CONSTRIJCTIO LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not 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:
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 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
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT."
Signature of Owner/ Lessee/Contractor as Agen f r Owner
Signature of Contractor/License older
STATE OF FLOR Dr
STATE OF FLORI[n
COUNTY OF a L.,L,I �
COUNTY OF P
The forgoing instCuWent was acknowledged before me
this day _ Lk k
The forgoing in,�ent was acknowled ed before me
�
"Zs
,� of 26 by
this day of �J L9�it \ Q 12 by
Name of person making statement.
Name of person makir(g statement.
/
J
Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification
Type of Identification
Produced
Produced
0",
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�GA OjA _V A 06A00AA
(Signature f ar) Publi State of Florida U
(Signature of Nota (u lic- St t of Florida)
Com s' "` ' KARLEYMARIEGIESYNARNEY
gR. te"4fFlorida eat)
KARLEYMARIEGIESY•VARNEY
Co p. (Seal)
CommissionkGG099801
omm. Exoires May 1, 20?1
=Florida
° e Commission # GG 099801
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SUPERVISOR
P
LE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev. 2/7719