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All APPLICABL FO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date:' % Permit,Number:�
971�WO- ,,j _` Building Permit Application
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Planning and Development Services O3AI303iil
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 CBDG Funding
PERMIT APPLICATION FOR
Address: q Vn 1t��' `, "_S(a KIT �0�1 �> w!VDP _ A
PropertyTax ID #: ��1 )� ��-1`` Lot No.
Site Plan Name: Block No.
Project Name:
New Electrical Meter
Second Electrical Meter
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(Affidavit required)
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: $/t Utilities: —Sewer —Septic Building Height:
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Name
Name:
Add s:9 \�6 ? Y
Company:
City: \� V C State — —IN
Zip Code: ` Fax: 1�
Phone No. 1��1�1— ��l� i , E-
Address:
City: State:
Zip Code: Fax:
Phone No
Mail: �lY��r��%Q�(G,1� y\C\6o 1,
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
E-Mail
State or County License
If value of construction is 2500 or morel a RECORDED Notice of Commencement is requirea. I
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
0
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 theissuance 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 conflicts with any applicable Homeowners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Homeowners 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
with lender or an attorney before commencing work -or recording vour Notice of Commencement.
Signatur f Owner/ Lessee Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF
Sworn to (or affir ed) and subscribed before me of C/ Physical Presence or Online Notarization
this-�3day of 2Q—'4 by
Name o son making statement.
Personally Known OR Produced Identifica
ion
Type of Identification Produced
„
(Signature of Notary Pu ic- State o*FTori
Commission No. (Seal)
;ot;iyPu"ec; AUDREYB.HUMPHREY
MY COMMISSION # GG.300817
EXPIRES: March 6, 2023
Bonded Thiu Notary Public Underwriters
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