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OFFICE USE ONLY:
DATE FILED: .QL•
PLAN REVIEW FEE: RECEIPT NO.:�i) PERMIT NUMBER
CONCURRENCY FEE: RECEIPT NO.: CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED
PLANNING & DEVELOPMENT SERVICES DEPARTMENT
BUILDING & CODE REGULATIONS DIVISION
2300 Virginia Avenue pp rn
Ft. Pierce, FL 34982-5652
772-462-1553 j`j b Cz . Teem Lo
APPLICATION for BUILDING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION
1. LOCATION/SITE ADDRESS:
2. PROJECT NAME: oOr/-Zf -"f 7;t4ip-j-4 C5&W2SITE PLAN NAME:
3. PROPERTY TAX ID #: 341 ¢ '�-D/ - -/ 9/2- -.S-b b -
4. LEGAL DESCRIPTION (attach extra sheets if necessary):
5. PLAT BOOK _� 6. PAGE No..3 S-SF.Cd-!a 7. BLOCK NO. 8. LOT NO.
9. PARCEL SIZE (ACRES/SQ FT.): LOT DIMENSIONS:
10.1 COMPLETE DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTMTY: /w7rfAz) /L ri� /yr� �CD
f £(l u
11. SETBACKS (ACTUAL) ROX90, Wfe ?�ACK: RIGHT SIDE: LEFT SIDE:
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
[ ] NEW CONSTRUCTION [ ] EXPANSION/ADDITION INTERIOR RENOVATION
[ ] RESIDENTIAL [ ] COMMERCIAL [ ] INDUSTRIAL
[ ] OTHER (SPECIFY)
13. DESCRIPTION OF PROPOSED USE: �fa.+ !L-4�t2 u/11rs%�tY�S eVyN��
14. SQ. FT OF CONSTRUCTION: 1440 15. SF. FT 1st FLOOR
o�
16. VALUE OF CONSTRUCTION: $ If-, 7Dv.
The value of construction is used to determine the amount of permit fees to be assessed. St. Lucie County reserves the right to question and/or modify the indicated
value of construction if it is demonstrated that the submitted figures are not consistent with similar types of construction activities. If the value is $2500 or more, a
RECORDED Notice of Commencement must be submitted with this application.
SLCCDV Form No.: 001-02
UPDATED 6/25/09
OWNER INFORMATION
NAME: eO /' M UA11 % Y
ADDRESS: 103 o�t�1S
CITY: Aor" S - %C £ STATE: ZIP: 3 ¢ � S L
PHONE (DAYTIME): 1 176- Email: ICNI LV f- iVS 0 0 02 6-
IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED ABOVE, PLEASE
FILL IN NAME AND ADDRESS BELOW.
FEE SIMPLE TITLEHOLDER 4116 W hV 6 ST, L. v Ct E /5 o e 141k s' LP
ADDRESS: 5-oS `UD2if- Zo 7* sT. S wT:�_ IwS' .,
CITY: �12,., iw� dsf�sc� STATE: s�� ZIP: 35�
PHONE (DAYTIME): (_)
CONTRACTOR INFORMATION
ST. of FL REG.CERT #: C&-C o 57 2_+7 ST. LUCIE COUNTY CERT #:
BUSINESS NAME:
S'eu fw?' ' CnA-
QUALIFIERS NAME: A&/L i O �✓�N �J T Tj
ADDRESS: S!o Z " .A 1yd*b0Nf2 044S
CITY: S j`y.A-1Lr— STATE: �� ZIP: 3 ¢ 11g
PHONE (DAYTIME): (� 3 � -¢?3 S- FAX NO.77A ZJ-0 - _a7 74 Email: Af aed LA &A-40A6144F,
ARCHIT/ENGINEER: hAW 9-rU,42rb4V, S Z
ADDRESS: 711 O Q S I :et- .31 D
CITY: P61q- .$ T&,' c 1f - STATE: ZIP: 3 4 7 Z
PHONE (DAYTIME): 71 3 43 - 63 40
BONDING COMPANY:
ADDRESS:
CITY:
STATE:
MORTGAGE LENDER
ADDRESS:
CITY: STATE:
ZIP:
ZIP:
IMPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification
it will be voided and returned to you by mail.
i { i
CERTIFICATION:
This application is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate of capacity,
if applicable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit,and that -all
work will be performed to meet the standards of all laws regulating construction in -this jurisdiction. I understand that separate.permits
--may -be-required -for ELECTRICAL- IL UMBING, -SIGNS, WELLS,_POOLS, -FURNACES, BOILERS, _HEATERS, TANKS,.
---AND.AIR-CONDITIONERS;FENCES,-ETC.,-riot,otherwiseinclpded-withthis`buildingpemrit-application. =-- - -
--
St. -Lucie -County makes `no representation that its__granting of a-permrt-will authorize the:permi -holder 10 build=the subject structure� - -
which is in conflict with any applicable Homeowner Associ=ali rules,15ylawsnr-any covenants-thafzriay restriet or=prohibit=such --
-structure.-Please-consult-with =your-Homeowner's_Association_and.reviewyoum_deed for any restrictions which,m y_qpply-.__ _.
The following building permit applications are exempt from undergoing Wa full�concurrency review: room -additions, accessory
str ctures (all. types),_ syswimming`pools, fences, walls, signs;- screen rooms, utility substations & accessory uses .to another non
- 'residential use.
NOTICE TO OWNER: YOUR FAiLURETO RECORDA NOTICE OF CO - MAY.RESULT 1N YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
- -- ->
-COMMENCEMENT-MUST BEap
ORDED AND POSTED'ON:THE JOBSITE. BEFORE THE
FIRSTINSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITHYOUR - ----
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
--COMNIENCEIVIENT:._.
NOTICE TO APPLICANT: IF TT'IS NOT -YOUR RIGHT, TITLES AND INTEREST THAT IS SUBJECT TO -
ATTACHMENT: AS A CONDITION OF ISSUANCE OF THIS PERMIT, YOUTROMISE IN
GOOD FAITH TO DELIVER A COPY OF THE CONSTRUCTION LIEN LAW NOTICE TO
THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT.
A
V
�r -
�jJ 3 7�
OWNER OR -CONTRACTOR SIGNATURE zM A CONTRACTOR SIGNATURE
STATE OF FLORIDAJ4. OSTATE OF FLORIDA
COUNTY OF = COUNTY .OF ItryT
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
:a
me this day of 20 i ' , t;� me this � 4 day of 20�
IF
Grp-
by m4 c ly V e nd a k�fe— by �1 f h d e R `P ,
who is personally known or has produced a who is personally know/1n� or has produced
moo U
as identification. a 70 as identification.
Signature of Notaryu
p M 9 Signat a of Notary
Commission No. (Seal) P Commission No. (Seal)
NOTE: TWO (2) SIGNATURES ARE REQUIRED. EACH SIGNATURE MUST BE NOTARIZED. IF APPLYING FOR
THIS BUILDING PERMIT AS AN OWNER/BUILDER, THE. OWNER MUST PERSONALLY APPEAR,TO SIGN
THIS APPLICATION IN THE OFFICE LISTED ON THEE FRONT OF THIS APPLICATION.
OWNER BUILDER AFFIDAVIT WILL BE REQUIRED FOR ALL OWNERBUILDER APPLICANTS.
i
For specific inptructions see appropriate permit checklist.
1 I .
OFFICE USE ONLY BP
SECTION
/_
TOWNSHIP
RANGE
MAP NO.
ZONING
/
6
LAND USE
LOT CVG %
TAZ NO.
FLOOD ZONE
FIRM MAP #
1ST FLR ELV
HGT
CONST TYPE
OCCUP TYPE
MAX P
# OF FLRS
WATER
SEWER
SPRINKLERS
STORMWATER
LOT OF REC
Before 1/1990-
L REC
After 1/1990
LOT SPLIT
REQUIRED
LOT SPLIT
APPROVED
REPORT
CODE
(J _/
HABITABLE
AREA
O
RADON
FEE
PERMIT
FEE
LIBRARY
IMPACT
FEE
PUBLIC BID
IMPACT FEE
CORRECTION
PUBIC BLD
IMPACT
FEE
GENERAL
PARKS
IMPACT
FEE
SCHOOL
IMPACT
FEE
ROAD
IMPACT
FEE
CREDIT
Y
N
LAW ENF
IMPACT
FEE
FIRE/EMS
IMPACT
FEE
DRIVEWAY
REQUIRED
Y
N
DRIVEWAY
FEE
ADMINISTRATIVE
VARIANCE FEE
SPECIFY
SUBS
REQUIRED
MECHANIC ROOF
ELECTRIC GAS
PLUMBING
NON -CONFORMING
LOT OF RECORD
FEES
MISCELLANEOUS
FEES
DATE SENT TO ADDRESSING:
REVIEWS
FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR
REVIEW
PLANS
REVIEW
VEGETATION
REVIEW
SEA TURTLE
REVIEW
MANGROVE
REVIEW
DATE
RECEIVED
e e
DATE
COMPLETED
O�• ZS'
INITIALS