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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED S_7
Date: Permit Number:
LLU Ctlf RRECEIVED
__:.�__•_ ,.r, =-- Building Permit Application JUL 2 0 2021
Planning and Development Services St.Lucie County
Building and Code Regulation Division Commercial Residential Permitting
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578
PERMIT APPLICATION FOR:
Address: O�c� T
Property Lot No.
Site Plan Name: Block No.
Project Name:
5I 3D�d I c, a, oo® C
New Electrical Meter Second Electrical Meter (Affidavit required)
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Additional work to be performed under this permit—check all that apply:
Mechanical Gas Tank _Gas Piping _Shutters i _Windows/Doors _Pond
Electric _Plumbing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: utilities: —Sewer —Septic Building,Height:
Name O�, A. _ Name:
Address: 0 �� "Ci Company:
City:�Q�Y 11�C�Q, State: Address: .
Zip CodeaAgS::) Fax: City: State:
Phone No ta2i,_ ������p Zip Code: Fax:
E-Mail: Phone No
Fill in fee simple Title Holder on next p ge(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.
FEE
DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _-Not Applicable
Name: Name:
Address: Address:
City: State: City_ State:
Zip: Phone Zip: Phone:
FEE SIMPLETITLE 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
with lender • n attorney before commencing work or recording our Notice of Commencement.
Signatuig of Owner/Lessee/Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF -S
Sworn to or affirm d�and subscribed before me of Physical Presence or Online Notarization
this ay of % 4— 2 by
�� - 'M
Name o person making statement.
Personally Known OR Produced Identification
Type of Iden . ''c ti n Produced
(Signature of Notary
�� ELLEN VAUGHN
rP�e�-State of ��IQor a-Notary Public
Commission No. _ = commlw� q # GG 270079
9� oe My Commission Expires
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED'
DATE
COMPLETED
Rev 5 2 2