HomeMy WebLinkAboutTemorary power pole permit BrooklineAll APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: _ /' � lag Permit Number:
C
Building Permit Application
Planning and Development Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1S53 Fax: (772) 462-1S78 CBDG Funding
PERMIT APPLICATION FOR:
PROPOSED IMPROVEMENT LOCATION:
Address: K a�7s
Property Tax ID #: o<:) .. V
Site Plan Name:
Project Name:
Lot No._
Block No.
DETAILED DESCRIPTION OF WORK:
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 Pitch
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction: $.a O.�t�} _ Utilities: Sewer _Septic Building Height:
.. ..
OWNER/LESSEE:
CONTRACTOR:
Name �.• • e , �,� =c l
Name:. 1 r C 5�; r, c
Company:
Address: ® f�-
City: for i , .kr State: LG
Address: _ S"G ( �>y^J ; 14mi c z `; i
I -
Zip Code: -7 '5_ Fax:
City: �oG`�-_ ccEc� roc o c� State:
Phone No. 7 70— -1 /) E-
Zip Code: S q Q �; Fax:
Mail: J ' Le -
Phone No - 6 y
Fill in fee simple Title Holder on next page (if diffe ent
E-Mail
from the Owner listed above)
State or County License
It Value or construction is `5uu 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.
I SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: Not App
Name: _
Address:
City:
Zip:
Phon
FEE SIMPLE TITLE HOLDER:
Name:
Address:
City:
Zip: Phone:
State
Not Applicable
MORTGAGE COMPANY:
Name:
Address:
City:
Zip: Phone:
Not Applicable
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,
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 an Y 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
i C]
Signature of Contractor - or - Owner Builder as applicable
STATE OF FLORIDA
COUNTY OF
Sworn taA(or affir ed) and subscribed before me of l Physical Presence or Online Notarization
thisday of_Lc_, ✓r' i' i' ., 20 2��by
tiJ
Name of person making statement.
,-
Personally known P' OR Produced Identification
Type of Identification Produced
A•°r
(Signature of NotaryPublic- state of Florida)
NALEpgg
Commission No. c Qao (Seal) * *
(Seal
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DATE
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DATE
COMPLETED
Rev 10712/21