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INFO MUST BE COM+a_: -ifED FOR APPLICATION TO BE ACCEPTED / r
SCAN Permit Number:
BY
St Lucie C05A
Building Permit Application
Planning and Development Services
em9,0
ding and Code Regulation Division
Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
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PERMIT APPLICATION FOR:
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Legal Description:
11
Propeerty Tax ID #:� �"�' �, ` Q �� Lot No.
Site Plan Name: Block Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
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Additional•t1
work to be • • • • • check aVthat —apply:
-�S4Gas,Piping —Shutters • • , • •
Plumbing Sprinklers • • •
Total
Sq-. Ft of 66nstructio'n: Sq. Ft. of First Floor:
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Name YV\ Name:' �� C i 6:: ` : ' Y
Address:13'j,, _QUI �i Q A-T Ham` RA _Company: Apt LL•-
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Citq;:l�t�-r'G�N —Mgupivs� State:Address: 17
Fax: City = `� `: 1� State:IP
Ph�one' 46-.I '72-,'t.,46 5 (65'3 zipCode ,J = ';b Fax::I�A
E-Ml' ail: Phone No Z?� Iq(olo
FiIII in fee simple Title Holder on next page (if different E-Mail
from the Owner listed above) State or County License A55-5
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER: _ Not Applicable -j
-.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:
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 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 intend to obtain financing, consult with lender or an attorney before
commencing work or recordin&your Notice of Commencement.
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Signature f-Own r/-L-essee/C-ontractor-as-Agent-gentOwners
Signature=of ntractor ;License Hol "ram
STATE OF // —
COUNTY OF FLORIDAT—Oal a,17 ��y'e r
STATE OF FLORIDA1/�J
COUNTY OF 70�4
The forgoing instrument was acknowledged before me
this a Xday of `' Vn R , 20 /V by
The forgoing instrument was acknowledged before me
this � day of eyi74 , 20L by
44w_� .li(
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(Name o erson acknowledging)
(Name of person acknowledging)
(Signature of Notary Public- State of Flor;allllllflf/��/
(Signature of Notary Public- State of Florida) ,
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PersonallyKnown 'OR Pro\\�Q� Nio /��i
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Personally Known OR Produc
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Type of Iden �'#'ication •CIN
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Produced iJrtiveis 1 i GO' a� m
Type of Identifi tion �� .•ogt1+M1 -sPa
Produced k1r, /C �' � t11�t�fr���•.'y
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Commission No. :.. ' • ; * =
Commission No. = Se �• r ;
REVIEWS FRONT ZO��/C, ��OR
PLANS VEGETATION SEA Tli � �t
COUNTER REVIE 11111110 EW
REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
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