HomeMy WebLinkAboutAPPLICATION FOR VARIANCEf�C_7
PLANNING & DEVELOPMENT SERVICES DEPARTMENT
BUILDING & CODE REGULATIONS DIVISION rim
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2300 Virgmia ve 1,
SCANNkU Fort Pierce, FL 34982
772-462-1553 ".
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Application for a Administrative Variance from the Provisions
of the St. Lucre County Land Development Code
Please complete the requested information below and submit all items .to the St. Lucie County Code
Compliance Division at the address listed above. The proper non-refundable application fee must
accompany all applications or they will not be accepted for processing. For assistance in submitting the
petition, please contact Zoning at 772-462-5296.
Applicant's Information
1. Name: MV�'1� (} Cam( �' `'� `Q
2. Address: ��a`Z 2 ' (/
Phone Number: a — o1a Qj `= S I Fax Number:
3. Location of Property Propos6d for a Variance: 5ZIM
4. Property Tax Identification Number (s): (attach extra sheets if necessary)
�451)2_ I - I7 7 12 - nrr� - 4�_
5. I (we) db hereby petition'the St. Lucie County Board Building Code Administrator for the following
variance from the St. Lucie County Land Development Code., (State the variance # of ft )
6. What is the purgose of the proposed variance
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7. State reasons why this variance will not be injurious to other property and/or improvements in the
neighborhood in which the subject property is located.
8. Please attach a d d
(;- % op
the dimensions of the lot and all other dimensions
necessary to understand this application.
DE RE�1/EFiUE
PHYSICIAN'S CERTIFICATION OF
TOTAL AND PERMANENT DISABILITY
4502 501-0712-000-5
identification Number
(;or appraiser use only)
pursuant to Chapter 458 or Chapter 459, Florida Statutes, hereby certify
r
Mr. T Mrs. Miss Ms. o; i i v _<_ <
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(checknne) t Patient's name
DR-416
R.02/08
, a physician licensed
Social Security Number) q 1 (,n is totally and permanently disabled as of January 1,
due to the foilowing mental or physical condition(s):
nOuadriplegia Paraplegia aHemiplegia legal -Blindness
I
k'Othertotal and pennanent'disability requiring use of a wheelchair for mobility
Please check here if patientlis totally or permanently disabled but does not require a
El wheelchair for mobility
I
(Social security number is required under section 196.101, Florida Statutes.)
It is my professional belief that the above conditions) menders this individual totally and permanently
disabled and that the foregoing statements are true, correct; and complete to the best of my
knowledge and professional belief. .•r
Signature --�—
Address.:.r, t .:
Date
F L '
Jk
cuy state Zip
Florida -Board of Medical Examiners license number
Vat e license issued
NOTICE TO TAXPAYER: Each Florida resident applying for a total and permanent disability exemption
must present to the county property appraiser, on or before March 1 of each year, a copy of this form or a
letter from the United States Department of Veteran Affairs or its predecessor. Each form is to be completed
by a licensed Florida physician.
NOTICE TO TAXPAYER AND PHYSICIAN: Section 196.131(2), Florida Statutes, provides that.any person
who shall knowingly and willfully give false informationunf or the
e b purpose farm claiming
homestead
oestea exceed exemption
7
shall be guilty of a misdemeanor of the first degree, p Yimprisonment
year, or a fine not exceeding $5,000, or both.
NOTE: Disclosure of your social security number is mandatory. it is required by sections 196.011(1) and
196.1o1(5), Florida Statutes.The social security number will be used to verify taxpayer identity information
and homestead exemption information submitted to property appraisers.