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All APPLICABLE INFO MUST BE . COMPLETED FOR APPLICATION TO BE ACCEPTED -
, '. - Date. . II .. : , .- I . - .'; : . 0*
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Pbrmit-Number:
SM. F� U111 (9 It
N-*YMM*'W, U�H)' Building Permit Application
Planning and Development SeNices
Building and Code Regulation Division -Com'm6rcial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 CB'DG Funding
PERmfT APPLICATION FOR:
77-
Address:_301;_ 09 HD(ILI" PM';. 71
Property Tax ID th Lot No.
Site Plan Name: Block No.
ProjecuNime:
77
New Electrical Meter Second Electrical Meter (Affidavit required)
Additional work to be performed under this permit check all that apply:
Mechanical Gas Tank !Gas Piping,' Shutters _Z'Windows/Doors Pond
Electric __L Plumbing _sprinklers 'Ginerator = Roof Pitch.
Total Sq. Ft of O Constru t' ion: Sq. Ft. of First Fio—oi�-. A 1. W, ' "1 0
Cost of Construction. iD D Utilities: —Sewer '_S6p6c_..-, 'Building Height
Name 1A�i-n(NANIffin,
Name:
Address: Idl�f IL4,
Company:
_2LJ
City: -,)V State: rL_
Zip Code Fax:
Phone No. -112 9,5,gqE-
Address:
City: State."7,,
Zip Co 'de: Fax
Phone No
E-Mail
Mal �aCo
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
State or County License'
if'value of construction is 2500 or more, a RECORDED -Notice of Comm6ncdiiient is requi red.
If value of I HAVC is $7,5�66,6r more, a RECORDED . . -Notice of Commericemen I t is required:
ired.r
DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: Not Applicable`
i Name -
Name:
I Address: i Address:
City: State: City: State:
Zip; Phone Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable BONDING COMPANY: Not Applicable
Name: game:
Address: Address;
i City: City:
Zip: Phone` Zip: Phone:
r
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 holdoi to build the subject structure
which conflicts with any applicable Homeowners Association rules,. bylaws or anij 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 reclut:sted permit, I do hereby agree that I will, in all respects, perform the work
in accordance with the ,approved olans, the Florida Building Codes and St. Lucie County Amendment,.
The following buddine permit apphcationsare exempt from undergoing a full concurrency r�vrew; room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory usk 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.
lttcie'Cou;nt�4and•postEid on the jobsite before the first inspection. if you intend to. obtain financing, consult
with„lP'nder o:r'aii attorneybefore commencing work i or recording your Notice of Commencement.
iMf
Sig ature of Contractor - or . Owner Builder as applicablo
STATE OF FLORIDA'
COUNTY OF 5tYI,v cue.
Sworn to (or affirmed) and subscribed before me of _ Physical Presence or Online Notarization
this - day of cl -1y�� , 20_%A, by
I Name of person making statement.
Personally Known OR Produced identification
Type of identification Produced i _L� PM'j Y23n_20_=_04,1 0
i
(Signature of'Notary Public- State of Florida) �Ri .yA ENID Y. QUILE5
#;F; <"s Notary Public- State of Florida
Commission No. 338p'of CommissianNGG938300
�seaq y Comm..Ezpires Apr 4, 2024
Bonded through Natlanil Not "Assn. i
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