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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
RECEIVED
1-0
-AUG 18 2021
Building Permit Application
St. Lucie County
Planning and Development Services Permitting
Building and Code Regulation Division Commercial Residential X
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
PROP�SED�IMPR01'/,EMENTL�CA�TIa�f,� µ ���� �""�
Address: 319 Shady Lane, Port St. Lucie, FL 34952
Property Tax ID #: 3419-510-0068-000/5 Lot No.12
Site Plan Name: Block No. 11
Project Name:
New Electrical Meter Second Electrical Meter (Affidavit required)
'i w ..�:.�,� -. � 'a; � .�a=, .„„ ,ate..-
C_O ll _,"ATR,U �(ON�IN� OR'MQTIO,Nt. �
Additional work to be performed under this permit —check all that apply:
_,Mechanical Gas Tank _ _ Gas Piping _ Shutters
Electric P umbing _ Sprinklers _ Generator
Total Sq. Ft of Construction:
Cost of Construction: $ c),0 O 6'0e a0
_ Windows/Doors _ Pond
Sq. Ft. of First Floor:
Roof Pitch
Utilities: —Sewer _ Septic Building Height:
OWNER%LESSEE
�CON�TRACTOR
` - 1 - r
Name Tina Ciechanowskl
Name: Co4441 Mewi Cb 4e
i n -146unSu
Address: 319 Shady Lane
Company: CW4-g ( i?C �/V►S t'Onsf %I
CI ipn
City: Port St. Lucie State: FL
Address: $ (0 5%t)
Zip Code: 34952 Fax:
City: ?O r-4- 54 Lt ol`.
State:,
Phone No. 772-359-1971
Zip Code: S q q 3-1 Fax:
E-Mail:
Phone No ,�7a--3Sq -iUq L-1
Fill in fee simple Title Holder on next page (if different
E-Mail C6464-41/hS CO er+e'eS
t , COM
from the Owner listed above)
State or County License Cg �y�
T.-
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.
SUPPLE MNTALC�NS�T ,,�"U li ,ON LIEN L �UV 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 instaliation 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 may 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,
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 atiattornem before commencine work or recordine vour Notice of Commencement..
Signat re of Own Lessee Con rac w �s
STATE OFF RIDA
COUNTY OF A%iRT/it/
Sworn to (or affirmed a�]d subscribed before me of ✓Physical Presence or Online Notarization
this � day of r� 20_7-1 by
Tina Ciechancwski
Name of person making statement.
Personally Known xx
Type of Identification
OR Produced Identification
(Signat4re of Notary Public- State of Florida )
,,• o APRILSiONCIUS
Commission No. (Seal) ; ;`�? Notary Public—StateofFlodda
y� ,. y ,: Commission II GG IG8177
";��j,,. My Comm. Expires Sep 19,2o21
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