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All APPLICABLE INFO MUST BE COMK�r'fJ FOR APPLICATION TO BE ACCEPTED Y
Date: Permit Number: 210
RECEIVED
91r. Lu0m: "` � AUG 24 1011
C 0 ��
V7 _.9 D�•FC`...-.— Building Permit Application permitting Department
p p St, 66 of Cgunty
Planning and Development Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR:
Address: k6
Property Tax ID #:
Site Plan Name:
Project Name:
New Electrical Meter
W�� AMPEA,
/� � i' l-
o'
Second Electrical Meter
(Affidavit required)
Lot No._
Block No.
Additional work to be performed under this permit — check all that apply:
on�
(/fVlechanical _ Gas Tank —Gas Piping _ Shutters _ Windows/Doors _ Pond
_ Electric _ Plumbing _ Sprinklers _ Generator Roof Pitch
Total Sq. Ft of Construction* Sq. Ft. of First Floor:
Cost of Construction: $ Utilities: —Sewer _Septic Building Height:
Name / "o'4"U^4h`P
Address:
City: n tl lifi�'L' State:
Zip Code: �J%� Fax:
Phone No.
E-Mail:
Fill in fee simple Title Holder on next page ( if different
from the Owner listed above)
Name: ®S
Company:
Address:
City: i C r� State: f 1�
Zip Code: Fax:
Phone No
i
E-Mail i/7/i� ✓� G'� _
State or County L eense Z
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.
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 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 br 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 taoI records of St.
�+ r
Lucie County and posted on the jobsite before the first inspection. If you intend t �� qr4 g, consult
with lender or an attorney before commencing work or recording our Notice cam( en`�
Q�Z_' RY1�?o P
Signatu e f Owner/ Lessee/Co tr ctor as Agent for Owner v �r gGG 300254
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STATE OF FLORIDA?
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oiv9Qy°.,t.NotaN,.•0�`�\\so®
COUNTY OF Li� `
BCIC'
SIN, \\\N
Sworn to (or affirmed) and subscribed before meiof Physical Presence or Online Notar1"uhm\
this _ day of 20_ by
Name of person making s ement.
Personally Known OR Produced Identification
Type of Id fication Produced /
(Signa re f Notary.Public- State of Florida)
Commission No. (Seal)
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