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Electrical Affidavit
Date
Parcel ID# 3�/� "5D� ' 0 :7 f i f- 200 "J�
Address 'LS 5 �-y O tc. A.
Permit#
I have requested to install an additional electric service/meter at the above named property. By
signing this affidavit, I fully agree that the additional electrical service/meter does not allow for
the following:
• Operation of a business venture or entity within the accessory structure
• Renting or leasing any portion of the accessory structure
• Converting accessory structure into additional occupied or living space
I fully understand that if the conditions of this affidavit is found in violation, power may be shut
off to the building without notice.
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Print Owner's Name Signature of Owner
STATE OF FLORIDA,COUNTY OFJ�M .VI�T7`tA
SWORN TO(OR AFFIRMED)AND SUBSCRIBED BEFORE ME 1OF PHYSICAL PRESENCE OR
ONLINE NOTORIZATION THIS _ —�+I'� DAY OF 20
NAME OF PERSON MAKING STATEMENT
PERSONALLY KNOWN V OR PRODUCED IDENTIFICATION
TYPE OF IDENTIFICATION PRODUCED
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SIGNATURE OF
NOTARY PUBLIC TYPE OR PRINT NOTARY
G ( V�/��tJ COMMISSION NUMBER
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Expires February 18,204
PLANNING&DEVELOPMENT SERVICES BUILDING DIVISION
1 2300 Virginia Avenue I Fort Pierce,FL 34982 (772)467-1553 123 (772)462-1428 LIP (772)462-1578 Q www.stlucieco.gov