HomeMy WebLinkAboutBUILDING PERMIT APPLICATION PAGE 2SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER ENGINEER: _ Not Applicable MORTGAGE COMPANY: Not Applicable
Name: Name:
Add ress: Address:
City: State: City: State:
Zip: Phone
Zip: Phone:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
BONDING COMPANY: Applicable
Name: _
_Not
Name:
Address:
Address:
City:
City:
Zip: Phone:
Zip: Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to dothe work and installation as indicated.
I certifythat no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representatlon that is granting a permit will authorize the permit holderto build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may
restrict or prohibit such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration ofthe granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in accordance with the approved Florida
plans,the 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.
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Signature of owner/ LessawlContractor as Agent forOwner
STATE OFFLORID9 { �GI�
COUNTY �3
OF
Sworep ,to (or affirme�tl-� jd _subscri .bed before me of _ Physical Presence or Online Notarization
thisI day of "L 20by
Name of person making statement.
Personally Known OR Produced Identification
pe of Identification Produced C�) `��aqunnntgn�,�
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(Signature of Notary Public- State of
Commission No.JaG a (Seal( w ;� 30.apy
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COUNTER REVIEW REVIEW
REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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