HomeMy WebLinkAboutMidwayPermitAppAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: 101051 al
Permit Number:
0
Planning and Development Services Building Permit Application
Building and Code Regulation Division Commercial X Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR: \f jndC)q) QLptaCeXYI �
PROPOSED IMPROVEMENT LOCATION:
Address:_35U M�dWCXq Q-Caul -'Fof+ Ili -ern 1, FI 34gs?_
Property Tax ID#: 3403 - 56Z- 0053 - CCQ- Lot No.
Site Plan Name:
Block No.
Project Name: M1awo-u Medi c_cj Q,!:_�Y
DETAILED DESCRIPTION OF WORK:
v4nu I iMPDX+ , Clkriy ril
New Electrical Meter Second Electrical Meter
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit - check all that apply:
_Mechanical _ Gas Tank —Gas Piping _ Shutters k Windows/Doors
Electric _ Plumbing _Sprinklers _ Generator _ Roof
Total Sq. Ft of Construction:
Cost of Construction: $ 10 . 03
Sq. Ft. of First Floor:
Utilities: —Sewer —Septic Building Height:
Pond
Pitch
OWNER/LESSEE:
CONTRACTOR:
Name lLC
Name: Ml(,Yy)&� \NQ i! Cj. cp
Address: 3514 f M i(1Wa,U
Company: lf)VIOVQ- jon CnalYCAC_6en Inn_
City: fby+ P I-ff c.c State: FL
Zip Code: 3LRS?_ Fax:
Phone No. _C-1-7 .) 5a(2 • 031 g
E-Mail: K h0 jdt n(c__0 Midu� LOX,' . OYQ
Address: PO gOX 3-141
City: Fur-t etv 2. State:'FU
Zip Code: 34g4E Fax:
Phone No 5 Ig , G (OR
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
E-Mail pCYrni1S� inrOV0.�l OnCdY1iYAC iYIA
State or County License C cr(1 I 1;5I lcl I c
If value of construction is 2500 or more, a KECUKDtu Notice of Commencement is requirea.
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: Applicable
_Not
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 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
corded in the public records of St.
improveme s to your property. A Notice of Commencement musrur
Lucie Co y and posted on the jobsite before the first inspection.ntend to obtain financing, consult
with le er or an torne before commencingwork or recc otice ofCommencement.
gnature of ner Contractor as gent for Owner
Sign t o ctor/License Holder
STATE OF FLORIDA
STATE OF FLORIDA
,
COUNTY OF SI-. Lu (a r.
COUNTY OF '4 . f ,,,, e,
Sworn to (or affirmed) and subscribed before me of
Swoyn to (or affirmed) and subscribed before me of
—,ZPhysical Presence or Online Notarization
V Physical Presence or Online Notarization
this � day of 1Joy rl+s h<<f 2020 by
/UItrY1r1E'.I r)"o'l c�� op
this q day of �m r 2020 by
f I r
Name of person making statement.
Name of person making tatement.
Personally Known OR Produced Identification
/
Personally Known OR Produced Identification ✓
Type of Iden 'fication
Type of Identification
Produced
Produced
"" •••FFRNANDO BETANCOURT
; ;a�'�� •.• FERNANDO BETANCOURT
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(Signature of Notary P i ;ofrSla�rll) 'Staten
A GG 194040
AFWA
Si nature of Notar Pub
( g y •� F scion GG 194040
Commission
�!� My Co Ex Ires Mar 11, 2022
Commission No. l"Jl7 •`'?`Bondedthro�onalNocaryAssn.
''e �c�. ,• My Comm. Expires Mar 11, 2022
Commission No. �(i Bondedthr Yl' ionalNataryAssn.
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FRONT
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SUPERVISOR
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MANGROVE
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COMPLETED
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