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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
01a LUQ11: - _ RECEIVED
�' :.�. 9 ?s 0 •'' tom_
SEp -0 2021
Building Permit Application
Planning and Development Services St, PerLuc�elttinun
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: V\ o,c � lq
Address: ` "
Property Tax ID t#: 7 [ ! a— Lot No.
Site Plan Name: PST! iM (�� Block No.
Project Name:
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.A �Iq� ?6t�G =4 d Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —Sewer _Septic Building Height:
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Name d P
Name: yy'f.
Address: 41GY
Company:
City: ry r t P. Ple-4 State: %/
Zip Code: Fax:
Phone IN'o. �„ � -45' E-
Address:
City: �2o"G State: ��-
Zip Code: -31 Z9 `% Fax:
Phone No / e) a G —
Mail:
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
E-Mail O�,-r t Mkt( C
State or ounty License Is-%%S FS
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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MORTGAGE COMPANY: _ Not Applicable
DESIGNER/ENGINEER: Not Applicable
Name:
Name:
Address:
Address:
City:
State:
City: State:
Zip: Phone
Zip: Phone:
FEE SIMPLE TITLEHOLDER:
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 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 job' ite before the first inspection. If you intend to obtain financing,,consult
WPTlener or ap-iattornev before commencing work or recording our Notice of Commencement.
Si ur f 0 n Lessee/Contractor as Agent for Owner
ST E F FLORIDA
C TYOF 'l C
Sworn to (or affirmed) angI subscribed before me of \40— Physical Presence or Online Notarization
this day of 20_ by
Name of person rhaking statement.
Personally Known '10 OR Produced Identification
Type of Id e tification Produced
(Signature of Notary Pu I State of Florida)
^^-
Commission No. O� Seal) AMYM.BOYD
;;1osv'Pu8-.;
r°; �•�� Notary Public - State of Florida
Commission # GG 301818
. ~�OF; My Comm. Expires Apr 1, 2023
Bonded through National Notary Assn.
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Rev 5/10/11