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Date: (D • Permit Number:
o -
RECEIVED
IT
Building Permit Application
Planning and Development Services 0 C T 0 7 202
Building and Code Regulation Division Commercial Residentiabt. ounty
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 CBDG Funding
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Address:
Property Tax ID#: j� �5�3-y���J_ (�(X)—� Lot No. / 7)
Site Plan Name: Block No.�
Project Name: ��{' l�1 C� cl�� 731/C b
DETAILED DESCRIPTION OF WORK:
/S®
New Electrical Meter Second Electrical Meter
CONSTRUCTION INFORMATION:
V6
Additional work to be performed under this permit -check all that apply:
(Affidavit required)
Ylectric
Mechanical _ Gas Tank _ Gas Piping _ Shutters _ Windows/Doors _ Pond
_ Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction:
Cost of Construction: $
Sq. Ft. of First Floor:
Utilities: _ Sewer _ Septic Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name to� bS �C�
Name: mml F -
Address: (onW 'j`Q.lk 116 "S VJ +M
Company.: Poo r GLC
City: 0: t ucg-, State: f-�—
Address 1S 6 S6 M AI(yJ/ E a)
Zip Code:, W1 �'Z Fax:
City: eb)/f ST. C IJC I e State: r! /
Phone No �Z fi'- E-
Zip Code:S�18_� Fax:
Mail: 1.1 4(4fsL
Phone No
Fill in fee simple Title Holder on next page (if different
E-Mail (P - ,LC-' �4611
from the Owner listed above)
State or County License 4/
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.
SUPPLEMENTAL 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
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 attornev before commencine work or recording vour Notice of Commencement.
Signature of Owner/ Lessee/Contractor as Agent for Owner
STATE OF FLORIDA
COUNTY OF
. u o'li'
Sworn to (or affir an�subscribed be or me of Physical Presence or Online Notarization
this day of 20by
1
-yyy)(N
Name of person making statement.
Personally Known OR Produced Ii entification
Type of Identifi tion ProdHced
LW
i
(Signature of Notary Public- S
e of Florida
Commission No.
�� avv� KA.REN S. NIELSEN
(Seal) 2o'P °< ;State of Florida -Notary Public
Commission # GG 207,484
,Expires
My commission
June
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