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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: VJ All, Permit Number:
�i Building Permit Application .
Planning and Development Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue,Fort Pierce,FL 34982
Phone: (772)462-1553 Fax: (t2) 462-1578 CBDG Funding
PERMIT APPLICATION FOR:PropertyTax
Site Plan Name: Block No.
Project Name:
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New Electrical Meter ! Second Electrical Meter (Affidavit required)
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Additional work to be performed under this permit—check all that apply:
Mechanical _Gas Tank _Gas Piping _Shutters _Windows/Doors ` _Pond
Electric _Plum i bing _Sprinklers _Generator _Roof Pitch
Total Sq. Ft of Construction: I Sq. Ft.df First Floor:
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Cost of Construction: $ /, 7(k) ^ 0 ® Utilities: _Sewe'' _Septic Building Height:
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Name R® M ,G E a,0 Name:
Address:Q0 S Iffick, 02 Company:
City: Fr P CrState: Address:
Zip Code: �?'fQo? Pax: City: State:
Phone No. 7 E- Zip Code: Fax:
Mail: RVAA I1111110,i/}:trTM�� Phone No
Fill in fee simple Title Holde i on next page (if different E-Mail
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from the Owner listed above) State or County License
If value of construction is 2500 for more,a RECORDED Notice of Commencement is required.
If value of HAVC is$7,500 or more,a RECORDED Notice of Commencement is required.
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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 jobsi before the first inspection. If you intend,to obtain-financing, consult
with lender or an attorneybefore co mencin work or recording our Notice of Commencement.
Signature of Contractor-ort Owner Build as applicable
STATE OF FLORIDA
COUNTY OF
Sworn to(or affirme )and s scribed before me of Physical Presence or Online Notarization
thifO day of 2�
Na)s�,
Name of person making statement.
Personally Known OR Prod ced 'Iden ' catig
Type of Identification oduc d= /
(Signature of Notar Pu - a e o Flo i s
a� E-IEN VAUGHN
Commission No. .b�P' B:'= ( .e� Florida-Notary Public
=* Commission # GG 270079
i�rE OF F��P� My Commission Expires
nnn` October 22, 2022
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev 10112121