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SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: Not Applicable
Name:
Address-XS I),4 s l � VEk 13LUID
City: 'E_ ae_- f ;'E_'-1Q - State: FL.
Zip: �, Z LG Phone F -
C;'
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name: _
Address:
City:
Zip:
Phone:
MORTGAGE COMPANY:
Name:
Address:
City:
Zip: Phone:
BONDING COMPANY:
Name: _
Address:
City:
Zip: Phone:
Not Applicable
State:
_Not Applicable
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 attorney before commencing work or recording vour Notice of Commencement.
Signature of Owner/ Lessee/C tractor `' Agent for Owner
Agent —�
In
STATE OF FLORIDA �OIa
COUNTY OF
Sworn to (or affirmed) and subscribed be ore me of Physical Presence or Online Notarization
this day of 2by
1DOd MCUa1-yWg
Name of person making statement.
Personally Known OR Pro ced Id ntification
Type of Identif'cation Produced (�1ZIRA DnQFTS-Uto se
(Signature of Notary Public- State of Florida)
I �I l!l 1 � AR Margarita Lowe
Commission No. try
eal) 4� Notary Public
Z State of Florida
Comm# HH144616
Expires 6/22/2025
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEA TURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev 5/20/21