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All APP
Date.
LICABL INF
MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
PER
Permit Number:
Building Permit Applicatto
ion
Phone: (772) 462 1553 Fax,. (772) 462w1578
ION FOR: E � � c I K I cAI
Addressb
PPLI C
Property Tax I D #19I
Site Plan Name
Project
Name
Commercial V residential
Lot No.
0 1
Block No.
NeNewElectrical Meter Second Electrical Meter (Affidavit required)
Additional work
Mec
hanica
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to be performed under this permit — check all that apply:
I _ Gas Tank _Gas Piping _Shutters
_Electric _ Plumbing _Sprinklers
_ Windows/Doors
Pond
Roof Pitch
Total Sq. Ft
0
0
Cost of Construction:
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Name V91IN
/-%(Jdress*,
ASO
City:
Zip CodeAW
:
4
Phone No, `lrl�—kf;
Fax:
Generator
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Zip Code: Fax'
E-Mail: I Phone No t _.: mom &`'ri��
Fill in fee simple Title Holder on next page I if different
from the Owner listed above)
If value o
If value o
f construction is 2500 or more,
E-Mail�sA'�:-�.��
State or County License..Ad—
a RECORDED Notice of Commencement is required.
T HAVC is 7,500 or more, a RECORDED Noti
ce of Cc mrnencement "s required.
State:
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DESIGN ER/ENGINEER:
Name:
Not Applicable
Address:
City: State:
Zip: Phone
FEE SIMPLE TITLE HOLDER: Not Applicable
Name:
Address:
:�f•... y^: CF •;itiy• ����MORTGAGE COMPANY, Not Appll*cableName,Address.
C'Ity: SZe *
1pe Phone:
BONDING COMPANY: Not ApplicabName:
Address:
City: I CitZip: Phone: Zip : Phone:
OWNER/ CONTRACTOR AFFIDVIT. Application is hereby made to obtain a ;:rmitt
I certify that no work or installation has commenced prior to the issuance of a permit.
o do the work and installation as indicated.
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 revie�%i 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 Countv Amendments.
The following building permit applications are exempt from undergoing
accessory structures, swimming pools, fences, walls, signs, screen rooms anci accessory uses to another non
itions,-residential use
wAKNINV 1 V UWNtK: Your failure to Record a Notice of Commencement may result in paying twice fimprovements to your property. A Notice of Commencement must be recorded in the public records of StLucie County and posted on the jobsite before the first inspection. If you in�end to obtain financing, consult__with lender or an attorne before commencir work or recording your Notice of Commencement.
7
Signatu
•i T•
Owner/ LesseeJContral`tor as Agent for Owner
STATE OF FC
COUNTY OF
Riga
Sworn to (or affix
this �day of _
med
i
and subscribed before me of
�,�•.I , 20,�1 by
Name of person making stat
ent,
i1 Q.r-
Personally Known �/ OR Produced Identification
Type of Identification Produced
a full concurrer.cy review: room add
Physical Presence or Online Notarization
(Signature of Notary Public- State of Florida ; _____����w w
Commission Na.
REVIEWS
DATE
RECEIVED
DATE
COMPLETED
ev ��
FRONT
COUNTER
(Seal)
ZONING
REVIEW
�J*" •��Notary public State of Floida
rgaret F Montepare
My Carwrusaion GG 214990
��ExpresO6lO5/2622
SUPERVISOR
REVIEW
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REVIEW
VEGETATION
REVIEW
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