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DESIGNER/ENGINEER: NotApplicable MORTGAGE COMPANY: _ Not Applicable
N a m e: Name:
Add ress Address,
City: St ate: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER: Not Applicable BONDING COMPANY: _Not Applicable
Name: Name:
Address: Address:
City: City:
Zi p: 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 ma y 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,
a ccessory 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- y Notice of Commencement.
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Signat re of Ow er/Lessee/Contractor as Agent for Owner Sig ature of ntractor/License Holder j
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STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF .T� � COUNTY OF
if
Sworn to(or affirmed)and subscribed before me of Sworn to(or affirmed)and subscribed before me of �
Physical Presence or Online Notarization I �Physical Presence or Online Notarization
thi ay of QCV��.35'1� ,�bY this� day of 2Q�bY
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-JIM�U 1` `1�4L1 � i1�1 ��Lti
Name of person making statement. Name of person making statement. �
Personally Known /` OR Produced Identification Personally Known OR Produced Identification
Type of Identification Type of Identification
Produced Produced I
Sig ature of N tary ubli State i moll re of N a ry ub -St I
Notary Public Slate ofFlorida �:'7��^� �"'a� ,N.o�y Public State of Florida
Com.missmn No. � 0..
�al onna Jayne Halt* Com sion No. + ( }a Bayne Hall
� My Commission GG 20 585 ,. < My Commission GG 207581
�xpres 04l1512022 Of %p Expires 04/1 512 0 2 2
RE IEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW i
DATE �
REC IVED
DA E
COMPLETED
ev. .5/6/20