HomeMy WebLinkAboutScan_0025.pdfSUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER:
Name:
Not Applicable
MORTGAGE COMPANY:
Name:
Address:
Not Applicable
Address:
City:
Zip: Phone
State:
City:
Zip: Phone:
State:
FEE SIMPLE TITLE HOLDER:
Name:
Not Applicable
BONDING COMPANY:
Name:
XNot Applicable
Address:
Address:
City:
Zip: Phone:
City:
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 County and posted on the jobsite before the first inspection. If you intend to obtain financing, consult
with lender or an attornev before comrnencina work or recording your Notice of Commencement.
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Signature of Owner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA 4,42,c�
COUNTY OF
COUNTY OF
Swoyrf to (or affirmed) and subscribed before me of
Sworn to (or affirmed) and subscribed before me of
Physical Presence or Online Notarization
Presence or Online Notarization
this _fL day of "im , 2020 by
__LZhysical
this ±L day of �,Aky1!Q _ , 20= by
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Name of person making statement.
Name of person m ing statement.
i
Personally Known OR Produced Identification
Personally Knowny OR Produced Identification
Type of Identification
Type of Identification
Produced1
Produced
(Signature of Notary Public- State of Florida)
(Signature of Notary Public- State of Florida )
Commis ' r. State of Forisbai)
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Commission No. (Seal)
Syr ru
ip r S:ettrtiPn�SSlori GG 13573&
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r 0! Notary FuO7 it State of Florida
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SUPERVISOR
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COUNTER
REVIEW
REVIEW
REVIEW
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REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.5/6/20