HomeMy WebLinkAboutAPPLICATION FOR BUILDING PERMIT CERTIFICATE OF CAPACITY-ZONINGSECTION:
ZONING:
FLOOD ZONE:
CST TYPE:
WATER:
40
TOWNSHIP: RANGE:
1 Cy/0
LAND USE: P 6-5 LOT CVG %:
FIRM MAP #:
OCCP TYPE:
SEWER: ;
LOT OF REC (befr 1/90) 1 1 LOT OF REC (aftr 1/90)
DECAL
NUMBER
LIBRARY
IMPACT FEE
REPORT
PUBLIC BLDG
CODE
3 C)4
IMPACT FEE
ROAD
GROSS ROAD
IMPACT ZONE
IMPACT FEE
DUE
R
SCHOOL- CREDIT
IMPACT FEE I I
POLICE FEE I FIRE FEE
ADDITIONAL SPECIFY.
PERMITS
REaD
I
1ST FLR ELV:
MAX. OCCP:
SPRINKLERS
LOT SPLIT
REQ'D
MISC FEES:
w
a:q E�-
'Ho
MAP NO.: 12]f)tIS
TAZ NO.:
W
MAX HGT:
# OF FLRS:
STORMWATE
R
LOT SPLIT
APPRV'D
PERMIT
FEE
RADON FEE
TOTAL ROAD
IMPACT FEE
TOTAL
SCHOOL
IMPACT FEE
TOTAL
POLICE/FIRE/
MISC. FEES
TOTAL ALL
FEES
REVIEWS ZONING' PLANS VEGETATION SEA 1% MANGROVE
REVIEWED BY, EXAMINING TURTLE
DATE
COMPLETE
INITIALS -
SCANNED
91UR BY
DATE FILED: 3T LUCIF COUNTY
PLAN REVIEW FEE: RECEIPT NO.: 509,77 PERMITNUMBER: 0(v 0
CONCURRENCYFEE: RECEIPT NO.: CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE u FILLED IN TO BE ACCEPTED
CpG i0e
p ST. LUCIE COUNTY PUBLIC WORKS
C-13 BUILDING &ZONING DEPARTMENT WRk6� fA je&V
2300 VIRGIN
AVENUE
0 FORT FxPIERCE, FIL -1553 34982-5652 -pre-55-
772-462
APPLICATION for BUILDING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION
1 LOCATION/SITE ADDRESS:
2. S/D NAME: SITE PLAN NAME:
3. PROPERTY TAX ID #:
3z
4. LEGAL DESCRIPTION (attach extra sheets if necessary): -0y-\,1-
5. PLAT 6. PAGE 7. BLOCK -8. LOT
BOOK NO. NO. NO.
4
9. PARCEL SIZE: ACRES/SQ FT. LOT DIMENSIONS
10. DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTIVITY:
v"
11. SETBACKS (ACTUAL) FRONT: BACK: RIGHT. LEFT
SIDE SIDE:
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
NEW CONSTRUCTION EXPANSION/ADDITION INTERIOR RENOVATION
RESIDENTIAL COMMERCIAL INDUSTRIAL
OTHER (SPECIFY) V,\ \r\
13. DESCRIPTION OF PROPOSED USE:
14. Sq. Ft./CONSTRUCTION: 15. Sq. Ft. 1st Floor:
16. VALUE OF CONSTRUCTION:
The value of construction Is used to determine the amount of permit fees to be assessed. St. Lucie County reserves the right to question and/or modify the
indicated value of construction if it Is demonstrated that the submitted figures are not consistent With similar types of construction activities. If the value is $2500
or more, a RECORDED Notice of Commencement must be submitted with this application.
M
N
SLCCDV Form No.: 001-02
OWNER INFORMATION:
NAME:
ADDRESS:
CITY:
CERTIFICATION:
This application is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate of
capacity, if applicable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit
and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that
separate permits may be required for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS,
TANKS, AND AIR CONDITIONERS, ETC., not otherwise included with this building permit application.
PHONE (DAYTIME): 7V �O� J D t d��pD-NN�C� �� �rj The following building permit applications are exempt from undergoing a full concurrency review: room additions, accessory�h y structures all es g p g y accessory IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE bWNER LISTED ABOVE, PLEASE FILL IN NAME AND ADDRESS ( types), swimming OOIS, fences, walls, signs, screen rooms, utility substations & accesso uses to another non -
BELOW. �^ residential use.
FEE SIMPLE TITLEHOLDER: a;r-- \N^�_ NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING
ADDRESS: TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
CITY: STATE: ZIP YOUR NOTICE OF COMMENCEMENT.
PHONE (DAYTIME): ( )
NOTICE TO APPLICANT: AS THE APPLICANT FOR THIS BUILDING PER IF IT IS NOT YOUR RIGHT, TITLE, AND
INTEREST THAT IS SUBJECT TO ATTACHMENT; AS A CONDITION OF THIS PERMIT YOU
CONTRACTOR INFORMATION PROMISE IN GOOD FAITH TO DELIVER A COPY OF THE ATTACHED CONSTRUCTION LIEN
7� LAW NOTICE TO THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT.
ST. of FL REG.10ERT #: (.- L ST. LUCIE COUNTY CERT #- ��c1
BUSINESS NAME: _�\�`� �'c�� �� OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance
QUALIFIERS NAME• with all applicable laws regulating Construction and Zoning.
ADDRESS: �• `L� \� V
CITY: e Va -c STATE. -ZIP - - �— OWN NTRACTOR-SIGNAT RE C-ONTRAC TOR-SIGNAT-URF
PHONE (DAYTIME): i��0� c� O� l� `, Q7T FAX NO. a
v STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF �� COUNTY O �.� 1_ C
ARCHIT/ENGINEER: ���v`� � �'C�-��
The foregoin -instrume was acknowledged The foregoing Ai�strum was acknowledged
ADDRESS: '''OC �l� E' efore e t day of .� 20� by _ before this "�C day o 20 6, by
e�w Is a known o r who C e
CITY:��`-� STATE: ZIP ha Uce as identification. o h1as produced as identification.
PHONE (DAYTIME): �� "' i� -7
Si ature of Notary Sign Ure of Notary
BONDING COMPANY: - \\
ADDRESS: Type or Print Name of Notary Type of Print Name of Notary
CITY: STATE: ZIP Notary Public Title Notary Public Title
MORTGAGE LENDER:
ADDRESS:
CITY:
STATE:., "'r ZIP
IMPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days_
after notification it will be voided and returned to you by mail.
Commission Number Commission Number
orao",
Kathalew A. Powell
(seal) MY COMM19810M D0160768 EXPIRES (seal) Ka11" A, Powell ;
ODtDbw 24, 2006 W C9MMIIt�lI" DD1WN 1XI4RE£
i30NDED THRU TROY FAIN INSURANCE, INC, bot V 24. �(i06
dONM THRU TROY NM IN`UIUNf7E, IPA
NOTE: TWO (2) SIGNATURES ARE REQUIRED. EACH SIGNATURE MUST BE NOTARIZED.
IF APPLYING FOR THIS BUILDING PERMIT AS AN OWNER/BUILDER, THE OWNER MUST PERSONALLY APPEAR
TO SIGN THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THIS APPLICATION.