HomeMy WebLinkAboutJackowski AC Permit app pg 2DESIGNER/ENGINEER: _ Not Applicable MORTGAGE COMPANY: _ Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOWER: _ Not Applicable BONDING COMPANY: _Not Applicable
Name: Addres_s_: ---------------
Name: _________________ _
Address: _______________ _
City: _____ ...,... __________ _
Zip: _____ Phone: _________ _
City:. ________________ _
Zip: Phone: -----------------
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a pennit to do the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a pennit.
St. Lucie County makes no repre,se,itation that is granti,w a Jll!nnit will authorize the pennit holder to build the subject structure
which is in conflict with any ;ipplicable Home Owners Association rules. bylaws or and C011e11ants that may: restrict or ~ibit 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 foftowing building permit applications are exemptfrom undergoing a full concurrency review: room additions,
acceSSOfy structures, swimming pools, fences, waifs, signs, screen rooms and aCO!SSOry 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 or an attorne before commencin work or recordin our Notice of Commencement.
Signature of OWner/ lessee/Contractor as Agent for Owner -
sTATE oF FLORIDA S\-Ludt.
COUNTY OF •
swo./4 (or affirmed) and subscribed before me of
Vi,i,:,_ical Presence or Online Notarization
this :ll SI-day of 51.fh,rn,liic , 2024 by
tl~:~rs!m~~tement.
Personally Known .,/ OR Produced Identification __
Type of Identification
Produced _______ -__
~ .4nwat:
C_HRIST/NE !OYCE CONWELL
otary Pub~• of F!~di,
Comlf!lisfon---nt 91,701.
Comm. Explr,s AIIJ 21, 202•
Signature of Contractor/license Holder
STATE OF FLORIDA c J.. 1 , ,,.;,,.
COUNTY OF ____ ~_,_,._~ ___ _
s----4(or affirmed) and subscribed before me of
_•--~ Ph:'.ysi•cal Presence or __ Online Notarization
this ~day of Stfkmn,,e . 202~ by
N~rsof ~S:~L~ent.
Personally Known ✓ OR Produced Identification __ _
Type of Identification Produced. __________ _
~ . ~dL
(Signature
Commission
REVIEWS FRONT
COUNTER
ZONING
REVIEW
SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
REVIEW
DATE
RECEIVED
REVIEW REVIEW REVIEW REVIEW