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All APPLICABLE INFO VST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: �`�G Permit Number: fir - 0309
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Building Permit Application
Planning and DevelopmentServices
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Building and Code Regulation I Division Commercial Residential
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax71 i ( 72)462-1578 CBDG Funding
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PERMIT APPLICATION FOR:
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ddress: IO�IO s 0. ea%N r- F- y_.* C 3Ygs
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Property Tax ID#: I-1 . "' (�t2 �� (201 � Lot No.
Site Plan Name: Block No.
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Project Name: I
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;New Electrical.Meter . I Second Electrical Meter (Affidavit required)
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IAdditional work to be performed under this permit-check.all that apply:
Mechanical Gas,Tank Gas Piping Shutters Windows/Doors —Pond
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—Electric —Plumbing —Sprinklers —Generator —Roof Pitch
I,Total Sq. Ft of Construction Sq. Ft.of.First Floor:
Cost of Construction: i -70 000 utilities: —Sewer —Septic Building Height:
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Name Name:; (•�lS 4fltc-eS ^ CJQ'L'
Address: 10SIOS.O 1' &Jr Company: P 0oisA-tu :_VAa A SSG,
City:�e+�1S£r1 �Qa�h State:—j Address: COI �kr%vofW Jc- S4 1551
Zip Code:_6M9kTJ- I Fax: State:
Phone No. 7 1- E- Zip Code:S3M 5% Fax: 1 -013S-4241
Mail: Phone No 641- r169 4 19b9
Fill in fee simple Title Holderi on next page(if different E-Mail Mflgo C+�I `r-C'ctYtc�c .on•Gacti1 '.
from the Owner listed above) State or County License CGC'- 152- 4_11 115
If value of construction is 2560 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.
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11 DESIGNER/ENGINEER: Not Applicable MORTGAGE COMPANY: Not Applicable.
i Name:}� 'no,°�,eer%a,& G*,• Name:
YY Address:��� uXlet. Hwy Address:
City: .va rI Stat} e City: State: i
Zip: _Phone 177_-25a• —oS-S Zip: Phone:
FEE SIMPLE TITLE HOLDER: Not Applicable BONDING COMPANY: _Not Applicable
Name: i! Naine:
Address: ! Address:
City: ! City
Zip: Pho ie: 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 instailation 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 confiicts 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..Lucle County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review:room additions,
dl 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 fender or an attorne before commendn .work or recording our Notice of Commencement.
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Signature of -or,,,Owner Builder as applicable
STATE OF FLgRIDA
1 COUNTY OF Ui,0 rA t; — LY4(YP
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Sworn to(or affirmed)and subscribed before me of k Physical Presence or Online Notarization
this-9day of (]Tt'l) .2012by
Name of person making statement.
Personally Known IOR oduced Identification
Type of Identification Produ
(Signature o blic-!State of Florida " JOCELYN MERCEDES S,OSA
fState of Florida-Notary Public
Commissio No, (Seal) Commission#GG 192217
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My Comm.Expires 03.05-2022
Bonded Through
American Association of Notaries
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