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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED �...
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Date: i�,ki�9�2��� Y" Permit N-q�
M. L�ll�cl�O��t11
= :•- Building Permit Application
Planning and Development Services
Building and Code Regulation Division Commercial Residential 111��✓
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
,
Address:
Property Tax ID #: �3'yl" W O'�� Lot No.
Site Plan Name: Block No.
Project Name:
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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 00 v Utilities: —Sewer _Septic Building Height:
OR
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Name:
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ess: Wo '¢x�L4�`'9 �L`�0
Company:
l.E't`C-State: F"-
r
Address:
City: State:
Code: -3CIf 1 Fax:
('`hone No. 77Z G7L -- `�.� 3
Zip Code: Fax:
E' Mail: ���Fr"�"L��� �z �Y � /� .CG^'1
Phone No
F11111 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.
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DESIGNER/ENGINEER: _ Not Applicable
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'arid 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 lender or an atto ne before commencing work or recording our Notice of Commencement.
;4re',iawner/ Lessee/Contractor as Agent for Owner
ST TE OF FLORIDA C
COUNTY OFy
Sworn to (or affirmed) and subscribed before me of _ Physical Presence or Online Notarization
this jd(,�ay of CA%r 20 by
Name of person making statement.
Personally Known OR Prod ed Identifi ation
Type of Identification Produced
(Signature of NotaryPub c-
VAorvubs ic
ELLEN
qtAtoolorida:tap079Commission fkI)270
ire
Commi
- mission E)
MY 0ort)etoger 22, 2022
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