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All APPLICABLE)�J� O1S; 13„1rj COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: JlJ �+Q E.W K Permit Number: r
LUaR
- ° "'" Building Permit Application
Planning and Development,Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue,Fort,Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578
PERMIT APPLICATION FOR:
ISS
Address:
Property Tax ID#: �i2.- � v�i J Lot No.
Site Plan Name: Block No.
Project Name:
New Electrical Meter Second Electrical Meter (Affidavit required) .. '
Additional work to be performed under this permit—check all that apply:
`Mechanical Gas Tank —Gas Piping _Shutters _Windows/Doors _ Pond
—Electric `Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft.of First Floor:
Cost of Construction:$ L 000 ` �V Utilities: _Sewer _Septic Building Height:
_ - fF.Yi -
':� '�c"
Name -NON-
�U- iu�- Name: "
Addres ll Pi,\_Q t e, Company:
City: State: Address:
Zip Code: Fax: City: State:
Phone No.=:') ^ —G Zip Code: Fax:
E-Mail: Phone No
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed above) State or County License
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
If value of HAVC is$7,500 or more,a RECORDED Notice of Commencement is required:
DESIGNER ENGINEER: Not Applicable/ _ PP 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 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
Wit der or an attorne before commencing work or recording our Notice of Commencement.
Si ature of 0 n /Contractor as Age or Owner
STATE OF FLORIDA
COUNTY OF S wu)_�^--
Sworn to(or affirmed)and subscribed before me of _Physical Presence or Online Notarization
this2_Lj�ay of 20 2k,by
Name of person making statement.
Personally Known OR Produced Identification"
Type of Identification Produce
P��
(Signatur
ELL
,St S
lP'�Y PUB i�
Commissi `�s rate of Florida-Notary Public
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Qc� My Commission Expires
011��,, �bibbfgF s2, 2022_-
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