HomeMy WebLinkAboutPermit ApplicationAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: "I I ,?)-) I Pefmit Number:
T 12 Building Permit Application
Planning and 0evFi'u;#nen11 Servirei
8uildtnq and CodePvytaotion oivisor, Commercial Residential
23W, Virgnio 4vertite Fort Pierce Ft 34982
Phone; (772)462,1553 Fax: (772) 462-1578 C8DG
PERMIT APPLICATION FOR:
.... . ......
I PRMSED IMPROVEMENT LOCATIT :,+,r-,o
Address�
Property Tax 0 L ot Nn,,
Site Plat) Name:
Block No,
Project Name:
New F lectriCaf Meter _-- Second Fkectncai (Affidavit required}
............. . ........ . .. -
CONSTRUCTION INFORMATION:
Additional work to bt! Performed under W5 permit - check all that apply:.
--Mechanical — Gas Tank — Gas Pipirg -- Shutte,s V00�induws#Doors Pond
.-- Electric 1 Plumbing Sprinklers --- Generator .1.111 Root 11 1 11 1 1 Pitch
Total Sq, Ft of Construction> Sq, Ft, of First Flcior;
%% IDO
Cost of Constructiom $ _L If----.__ . I __ 4 Building Height;
OWNERAESSEE�
CONTRACTOR.
Na me
Narni,,
c
I I
Adrdress:
city, _.sly WPI. Addre-,A.5 K"41 WAO�'. 551 fll.4.b
Zip Code,, Fax: City,
State, 4!
mPhone No. 75 E- Zihp code:
C A-L
Fax:
at" Pon- No-114?171---3-RA—
Flit In fee simple Title Holder on next page (if different E-Ma 1,
State or County tcense
from the Owner listed above)
" vfa
If value of construction is 2SW at mere, a RECOR66vo;ti—c"i menimment is required-
if value of HAVC is $7,500 or more, a RECORDED, Notice of Commencement Is required.
DESIGNERIENGINEER: v,' Not Applicable
Narne,
Address:
City: State:
ZiP:,,--- Phone------,
FEE SIMPLE TITLE HOLDER: .1?!" Not Applicable
Name.
Address-,
City:
Zip..__ _Phone:
i MORTGAGE COMPANY: Not Applicable
Name:
Addiess:
City:
zip� Phone�
BONDING COMPANY-
Narrie;
Address
Zip: Phone -
.!',Not Applicable
OWNER/ CONTRACTOR AFFIDVIT: Application's hereoy made to obtain a permit M 1 t 0 do the wr�rk and mstaisir!on as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit,
St, Lucie County makes no re resentatiori that is qi�antinfi a permit will aL,thorize the permit holder to buiid the subject structure
which conflicts with an i spcable Homeowners Assoqat!on rul�s, bylaws or and covenants that may res-aict or prohibit such
structure, Please cons�, , with your t4omeowneri; Association and review your deed for any restrictions which may apply,
In consideration of the granting of this requester permit, I do herpbv agreq, that : will, irt aP respects perform the work
in accordance with the approved plans, the Florida Building Codes and St Lucie county Amen dmeriV'
The following builcffng ')ermit applications are ex"lpt from widergoing a toll concurrency review. roans ad&1iomi,
accessory structwes smnming pools, fences, w,ifts, signs, screen rooms w,,d accessory uses to another rioq•restdiirtt4 L-se
WARNING TO OWNER: Your failure to Re,:ord 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 Count'� arid posted on the jobsite before the first inspection, if you intend to obtain Financing, consult
With lender or in attorney before comrnencinR work or recordin ypyr l 9c ice ot'Commencemexit
,
Sigt ature of Owner/ is ssett,kCorltratinr as Agent for Owner
STATE OF FLORID4--
COUNTY OF z-
Swc n to r affirmpa) and subscribed before,, rn8 of privsical of Qnline NCAZ162 aCW�
V of 20k� by
14 1`5 V4-
Name of person mai�tng statement,
Personally Known OR ProOuced tdentihcat:cin
(Signature of Notary Public -State of ELIZABETH SMITH -WOOD
Commission # HH 166395
Cufnrnission No (Sea0; �z Expires July 21, 2025
k,,,ded "t" Troy Fain insurance W-W-17019
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