HomeMy WebLinkAboutAPPLICATION FOR BUILDING PERMIT- '--r---
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PLAN REVIEW FEE: O-V RECEIPT NO.: �L(7'T t , ! ER: ���'" o
CONCURRENCY FEE: _��: 6D RECEIPT NO.: NO.:
ALL INFO MUST BE COMPLETE & FILLED N0 BE ACCEPTED
St. Lucie County Building and Zoning,. ec 177 e-
• �• 2300 Virginia Avenue l
OR1D Ft. Pierce, FL 34982-5652 �C
1 772-462-1553
APPLICATION for BUILDING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
{ ROJECT INFORMATION
—. NQ d to b
1. L1ec�S �9tJ'Ir�
0CATION/SITE ADDRESS: "' �`a '�� PS
2. S/D NAME: SITE PLAN NAME:1"'i
3. PROPERTY TAX ID #:�
4. LEGAL DESCRIPTION (attach extra sheets if necessary):
5. PLAT 6. PAGE 7. BLOCK 8. LOT
BOOK o NO. NO. NO.
Pfrc_—_ rc,f
I. PARCEL SIZE: ACRES/SQ FT-- - LOT DIMENSIONS
10. DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTIVITY:
SETBACKS (ACTUAL) FRONT: 5o BACK: RIGHT: LEFT:
SIDE t--T SIDE
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
NEW CONSTRUCTION [ ] EXPANSION/ADDITION (] INTERIOR RENOVATION
[ ] RESIDENTIAL (] COMMERCIAL-: [ ] INDUSTRIAL
[ ] OTHER (SPECIFY) 4
13. DESCRIPTION OF PROPOSED USE:-•����s�apv �1eo�CM-�QC
Z/,7-1z /s
14. Sq. Ft./CONSTRUCTION: /Sj 7z./ S 15. Sq. Ft. 1st Floor:
�� 7�4FS3
O Q
16. VALUE OF CONSTRUCTION: $
Pae 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
lue 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.
SLCCDV Form No.: 001-02
CERTIFICATION:
OWNER INFORMATION 11 + (� r�
NAME: GSA 11ti71 "t �C9'�' 1
ADDRESS: C\ �CA �W+� 5MV
i�i Y�
CITY: ' )PI STATE: �— ZIP
PHONE (DAYTIME): ( ) email:
IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED ABOVE, PLEASE
FILL IN NAME AND ADDRESS BELOW.
FEE SIMPLE TITLEHOLDER:
ADDRESS:
CITY:
PHONE (DAYTIME):
CONTRACTOR INFORMATION
ST. of FL REG./CERT #. (16 C
BUSINESS NAME:
QUALIFIEF
ADDRESS:
N
STATE:
h�2 to
ZIP
ST. LUCIE COUNTY CERT #:
V
l_�
o2 5tc?
CITY: ISM` STATE: 54VIDA ZIP
P-HONE-(DAYSIME): ( -2.:L
—O • Qom✓ FAX NO. 15. O (,P51S email: 1 'u
ka
Per: I`1�4.un al�zC;�4
CHIT/ENGINEER-
ADDRESS: � � (Ji-13i� �G�®�•% `�?��y� ��� 2t�
CITY: STATE:ZIP I.a`�1 tip► 1 S,o
PHONE (DAYTIME): J `�� ' �"®� X 105
BONDING COMPANY:
ADDRESS:
CITY: STATE: ZIP
MORTGAGE LENDER:
ADDRESS:
CITY: STATE: 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.
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.
The following building permit applications are exempt from undergoing a full concurrency review: room additions, accessory
structures (all types), swimming pools, fences, walls, signs, screen rooms, utility substations & accessory uses to another non-
residential use.
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TOYOUR PROPERTY. IF YOU INTEND TO
OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
NOTICE TO APPLICANT: AS THE APPLICANT FOR THIS BUILDING PERMIT, IF IT IS NOT YOUR RIGHT, TITLE,
AND INTEREST THAT IS SUBJECT TO ATTACHMENT; AS A CONDITION OF THIS
PERMIT YOU PROMISE IN GOOD FAITH TO DELIVER A COPY OF THE ATTACHED
CONSTRUCTION LIEN LAW NOTICE TO THE PERSON WHOSE PROPERTY IS SUBJECT
TO ATTACHMENT.
OWNER'S AFFIDAVIT:
I certify that all the foregoing information is accurate and that all work will be done in compli e
with all applicable/laws regulating construction and zol 'ng
SIGNATURE CONTRATOR IGNAT
STATE -OF FL A -
COUNTY OF K A ✓" 1 -Da
The foregoing instrument ac mowle C1
before me this QL day of y
, who 's personally
known to me or who has produ ed
as identification.
of
Type or Print Name of
Commission N
—_LyuKUES ALVAREZ VEGA
ry Public - State of Florida
Commission Expires Jun 12, 201
al) Commission # DD 528363
Bonded By National Notary Assn
STATE OF FLA4�
COUNTY OF
T-he-foregoinginstrument wa . acknow�leded
before me this �� day o d f 2u�'1 by
who ' personally
known to me or who has produced
Type or PriwwotaryAssn.
ate of Florida
res Jun 12, 2010
Commissio9D 528363
l NotaryAssn.
NOTE: TWO (2) SIGNATURES ARE REQUIRED EACH SIGNATURE MUST BE NOTARIZED. IF APPLYING FOR
THIS BUILING PERMIT AS AN OWNER/BUILDER, THE OWNER MUST PERSONALLY APPEAR TO SIGN
THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THE APPLICATION.
For specific instructions see appropriate permit checklist.