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All APPLICABLE INFO MUST BE
BE COMPLETED FUR APPLICATION'TO BE ACCEPTED
Date: I O"cJ Permit Number: 4�
RECEIVED
L ` o LUFQ!L--„A DEC 2 8 2021
..
wilding Permit Application St. Lucie County
Permitting
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 CBDG Funding
PERMIT APPLICATION FOR:
Address: 14t ' "
Property Tax ID #: 1 q3 t p 000 I '- 006 - � Lot No.�1
Site Plan Name:
Block No. uU
Project Name:
New Electrical Meter
Second Electrical Meter.
(Affidavit required)
r �
COiUSTRUCI iON �NFORMATICiN y
fr
Additional work to be performed under this permit— check all that apply:
_Mechanical _ Gas Tank _ Gas Piping ^ Shutters _ UVindows/Doors _ Pond
_ Electric — Plumbing _ Sprinklers _ Generator _ Roof Pitch
Total Sq. Ft of Construction: 3" "' Sq. Ft.. of First Floor:
Cost of construction: 45.— Utilities: ,Sewer _Septic Building Height:
3xt�11VIE/LES�Ex{Ca1TR
OtO
Name cam' „r�\\r
Name: ^AAA&er4 6R1ATf12
Address ��1 S 1 ST G� Q\�1
Company: &-l` TEe— s1(3gs- IN L
City; ` o r� P _ State: '�—
Zip Code: _ �lg`1 __._ Fax:
_
Phone No. \ O E-
Address: lb- ICJ�7 t>W 4
city: i(�� 1kp N State: t Ir
Zlp Code: _'N pO Fax:
Phone No ? -' ., -qD.&3
Mail:
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
E-Mail h>ri I-}3N" 5l6 k� - �: 0(� (` L-
State r County Licenses
if value of construction is ZSuu or more, a Ktt-uKUtU lvOvice U1 1a —4-1—
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
11
DESIGNER/ENGINEER:, Not Applicable
Name:
Address:
09
City: Iyw- �,t t( f State: _
Zip: � S< Phone --I `f 3�
FEE SIMPLE TITLE HOLDER: ✓ Not Applicable
Name: _
Address:
City: _
Zip:
Phone:
MORTGAGE COMPANY: Not Applicable
Name:
Address:
City: State:
Zip: Phone:
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 lender or an attorney before commencing work or recording our Notice of Commencement.
Signature =w e ";Lessee ntractor as Ag for Owner � C�p alp �I RASI�1�•
STATE OF FLORIDA_ 6TAT£ 0IP F—W12-10W j bofj i o IF l o
COUNTY OF n. nPC.- war r -� o (� v►�w� a 9D`d I
Sworn to (or affirmed) and subscribed before me of Physical Presence or Online Notarization
this f b day of k4OV zoo by 1�„ a1�Q �,;�eE � SIfY1a �(� 9h.4u.v
Name of person makin 'statement.
S l� u1�diU►c ty v; .;lair ens., DIANA L. BRYANT
Personally Known OR Produ ed Identification Q,t� _�•����:. Notary Public - State of Florida
pe ldentific roduncedCommission # GG 940061
Bonded
My Comm. Expires Feb 22, Notary
1 � Borded through National Notary ASS(
(Signature coiotary Public -State of Florida) „YP;,,, PAIGE PEELS
01'v
a
�Notary Public -State of Florida
Commission No. � Sehl) _= Commission # GG 266219
OFP��\�` My Commission Expires
October 14, 2022
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