HomeMy WebLinkAboutBUILDING PERMIT AFFIDAVIT All APPLICABLE,INFOI MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: Permit Number:
C_D �4 .I
r e C, u� L c z1 - Building Permit Application
Planning and Development Services
Building and Code Regulation Division Commercial Residential1
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 CBDG Funding
PERMIT APPLICATION FOR: ` �,
PROPOSED IMPROVEMENT LOCATION: ,/
Address: ( G 1�� ! !S 1(.! L��- [Q c-ad
Property Tax ID#: LIUq— I t L/i) 7 Lot No.
Site Plan Name: )�I A- L Block No.
Project Name:
DETAILED DESCRIPTION OF WORK:
any ern-s 16c_ !:�aT—
New Electrical Meter Second Electrical Meter (Affidavit required)
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit—check all that apply:
Mechanical _Gas Tank _Gas Piping _Shutters Windows/Doors _Pond
Electric Plumbing _Sprinklers _Generator Roof 1 Z Pitch
Total Sq. Ft of Construction: 3911 Sq. Ft. of First Floor:
Cost of Construction:$ Utilities: _Sewer Septic Building Height:
OWNER/LESSEE: CONTRACTOR:
Name LI—n Name: L 1
Address: Company:
City: }�� 'f7 rAL`r e State: 7�j Address:
Zip Code: Fax: City: ./k 5±. Lke—I-£ State:
Phone No. 4 `c_2 Y 3- c2&4, E- Zip Code: __-3 t{ q SS'&) Fax:
Mail e4� I Phone No-5 t , f — 3 )! •—---3 3 1-7
Fill in fee simple Title Holder on next jAge (if different E-Mail
from the Owner listed above) State or County License t;
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:
DESIGNER/ENGINEER: _ Not Applicable MORTGAGE COMPANY: _ Not Applicable
Name: L_', i' I I ,_-i n cn"7Ql-e-2— Name:
Addr /,�, �f—�i�'C��r�.—,� n Address: / _ Z
City: State: City: State:
Zip: Phon 54�1,��1�(�,���/ 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 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.
l.�
SigncYture of Contractor-or-Owner Builder as applicable
STATE OF FLORIDA ��
COUNTY OF r� L )Ull c—1,
Sworn to(or affirm an subscribed bef re me of Physical Presence or Online Notarization
this/U day of 6, 2by
vqa r1 l) 15
Name df person making statement.
rsonally Known OR Produced Identification
Typ of Identification Produced ` � /
\������NE LYNN ply
(S g ature of Notary Public- to of Florida) _ : � ?o %p�,• Z
Commission No. (Seal)
ti
�Fil 1122934
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STX
REVIEWS FRONT ZONING SUPERVISOR P195iR tO`GETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
ev 10/12/21
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