HomeMy WebLinkAboutScan 4SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:
DESIGNER/ENGINEER: _ Not Applicable
MORTGAGE COMPANY: Not Applicable
Name:
_
Name:
Address:
_
Address:
City: State:
City: State:
Zip: Phone
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.
Signature of CcFntfactor - or - Owner Builder as applicable
STATE OFF ORIDA
COUNTY OFJ
__00ICJ�v
Swor to (or affirm any���+bscribed before me of Physical Presence or Online Notarization
this + day of (�1 1 2021by
Sic If n S
Name of person making statement.
Personally Known OR Produced Identification
p of Identif' i Produced CLhK
( 'nature of Notary Publ' -State of Florida)
Mahal Lacy
Commission No (Seal)
�O�ARyASJ' NOTARY PUBLIC
OF FLORIDA
-+STATE
o = Comm# GG311481
•s�NCE 19�� Expires 3/13/2023
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEATURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETED
CV 1V/1L/L1