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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Dates:y Permit Number:
LCL-FeUL
Building Permit Application
Planning and Developmenr Services
Building and Code Regutntfort Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 CBDG Funding
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Address. I NIL S
Property Tax ID R: dog —3 Lot No.
Site Plan Name: Block No.
Project Name: •,n �p
DETAILED DESCRIPTION OF WORK:
rx S C" ha
New Electrical Meter Second Electrical Meter (Affidavit required)
[KO7NSTRUCTION INFORMATION:
Additional work to be performed under this permit— check all that apply:
_Mechanical — Gas Tank —Gas Piping Shutters —Windows/Doors _ Pond
- 4 Electric — Plumbing _Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: Utilities: Sewer _ Septic Building Height:
OWNER/LESSEE: CONTRACTOR:
Name �, _ _ Name: ( n,
Address; o Company: !Cynpe ktt,M%L
City: lax St Lk P-9 State: fL Address:_ 5S14 I K uW
Zip Code:Fax: City; 1- ).�^^
State:
Phone No. E- Zip Code: _3 415�e Fax:
Mail; Phone No 3-4 �p 1
Fill In fee simple Title Holder on next page (if different E-Mall uw1 [. C. t.OV%
from the Owner listed above) State or County License tap
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:
Dff1 NER ENGINEER: _ Not Applicable MORTGAGE COMPANY: Not Applicable
Name: Name:
Address. Address:
City: State: City: State:
Zip: Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER:
Name:
Address:
City:
Zip: Phone:
Not Applicable
BONDING COMPANY: Not Applicable
Name:
Address:
City:
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 lee';A attornev before commencing work or recording your Notice of Commencement.
44'/
Signature of er Lessee/Contractor as Agent for Owner
STATE OF L IDA _S7— /- LX
COUNTY OF
Sworn to (or affirmed) and subscr' ed before me of
thls�dayof nt)l��dt_-20�by
Physical Presence or Online Notarization
�� CO2c;?e. AU r z ORf1 z
Name of person making statement.
Personally Known OR Produced Identification
Type of ldentification Produced
�kl P-�Z—
(Signature a Notary Public- State of Florlda)
Commission No. 3 (Seal)
—
yr* YAOYRA MAFMNEZ GONZALEZ
; „� `y Notary Public • Stite of Florida
+ COMMIStilon 0 HH 11A10
4 My Comm. Explrel Aug 30, 20I4
bonded through Nitlonal Notary Ann,
REVIEWS
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SUPERVISOR
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PLANS
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SEA TURTLE
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MANGROVE
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DATE
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BATE
COMPLETED
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