HomeMy WebLinkAboutScan_0004SUPPLEMENTAL 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:
Not Applicable
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 County and posted on the jobsite before the first inspection. If you intend to obtain financing, consult
with IQndsir or an attnrnPv hpfnre commencing work or recordine vour Notice of Commencement.
Signature of Owner/ Lessee/Contractor as Agent for Owner
Signature of Contractor License Holder
STATE OF FLORIDA (
STATE OF FLORIDA T
COUNTY OF ► (LLUT-1
COON OFF UD-�`�
Swor to (or affirmed) and subscribed before me of
Ph sicai Prese a or Online Notarization
Sworn (or affirmed) and subscribed before me of
Presen je or Online Notarization
this 1 day of 2028 by
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this M4 day of ��iJl�1+ � _ _ _ J 2021 by
Name of person making statement.
Name of person making statement.
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Personally Known OR Produced Identification
Personally Known OR Produced Identification
Type of Identification F
Type of Identification
Produced
Produced
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(Signature of Notary Public- State of Florida j
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REVIEW
REVIEW
REVI•E
REVIEW
DATE
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DATE
COMPLETED
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