HomeMy WebLinkAboutScan_0011.pdfSUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
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
Y applicable Homeowners -Association rules, bylaws or and covenants that may restrict or prohibit such
which conflicts with an
structure. Please consult with your Homeowners As 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 or an attorney before commencing work or recording our Notice of Commencement.
V .
Signature of owner/ Lessee/Contractor as Agent far Owner
STATE OF FLORIDA
COUNTY OF
Sworn t (or affir ed) nd ubscribed before me of Physical Presence or Online Notarization
this�day of 20 Dt by
cA-
Name of person making statement.
Personally Known OR Produced Identification
Type of Identification Produced
Signature of Notary Public- State of Florida)
Commission No. �� Nai�ry p�plic stale of Fiooda
Suzette Ritchie
Commisaion GG 135736
• or t+ Expires 121I D2021
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED