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ALL APPLICABLE INFO MUST BE fay_ �,PLETED PqR APKICATION TO BE ACCEP'
Date: Pemit Number:
SCANNED
BY,
St LWiffliffivilPermit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue, Fort Pierce FL 34982
MAR 2 2 2010
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
PERMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PROPOSED IMPROVEMENT LOCATION:
Address:
Legal Description:
Property Tax ID #:
Site Plan Name:
d/W r 8/
Project Name:
Setbacks Front Back: Right Side:
Left Side:
X
Lot No.
Block No.
DETAILED DESCRIPTION OF WORK:
iial� of _ u/ AftU
CONSTRUCTION INFORMATION:
Mclitional work to be nerformed under this ermit — c ec a apply:
OHVAC Gas Tank gas Piping ri
_Shutters1:1 Windows/Doors
OElectric 0 Plumbing OSprinklers Generator Roof
Total Sq. Ft of Construction:
Cost of Construction: $ Z200
S Ft. of First Floor: _
Utilities:Sewer Septic
Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name1���j{/
Address:
Name: ��% F,t/,//� /.�6.�
Company: —zw--
City: G'i� State: AA
Address:
Zip Code: 3 Fax:
Phone No. — �� ��
City: AQy Stater
Zip Code:.�yQ9/
E-Mail:
Phone No. 77QZ 2W ?4y8
Fill in fee simple Title Holder on next page (if different
E-Mail:AdregiO3
from the'Owner listed above)
State or County License: Z25I80
If value of construction is 52500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTR '
ON LIEN LAV 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:
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 is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Home Owners 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 your paying twice for
improvements to your property. A Notice of Commencement must be recorded and posted on the jobsite
before the first inspection. If you intend1to obtain financing, consult with lender or an attorney before
commencing work or recording vour Notice of Commencement.
s
F 02:1=0111� — 6&V5nt4_e ex —
_ Signature of Ow L see/Agent Signature of &6ntrqdo_r/LicenstMoIder
STATE OF FLORIDA
COUNTY OF
The forgoing instrument was acknowledged before me
this/ day of /%%XoRell 20 /.Pby
STATE OF FLORIDA
COUNTY OF
The forgoing instrument was acknowledged before me
this -o3l day of 20/1L by
(Name of person acknowledging) (Name o person acknowledging)
(Signature of Notary Public- State of Florida) ,(' nature of Notary Pub
04ppY PVe�,•.
Personally Known "'� 6, Prodd 11d n �' Personally Known
c ALYSSA A 109 €
Type of Identificatio Igo_ Type of Identification Pr
904 OF �•...
:"��� ��'� (407) 398-0153
',!F'oFFo? ` EXPIR ne 9, 201 S
Commission No. �ah9' Commission No.
(407)'398-0153 FloridallotaryService.com
Revised 07/15/2014
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