HomeMy WebLinkAboutBUILDING PERMIT AFFIDAVITAPPLICABLE INF MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED q
te:1 a Permit Number:
.. MANNED
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Building Permit Applicati n JUL 1 2 2.01$
nning and Development Services Permitting
Ming and Code Regulation Division S `Lucie County,
70 Virginia Avenue, Fort Pierce FL 34982
one: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential X_
P RMIT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
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Pr Iperty Tax ID #: IkAMV - 1 as - 000a- 000 - Lot No.
Sit I Plan Name: "04-h Block No.
Pr 'ect Name: N1 QA- o
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Name
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Fill i i fee simple Title Holder on next page ( if different
from the Owner listed above)
Name:
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Address: \\ "3ke k_-Yt) "AW \
City: State.f-L_
Zip Code: �4JR Fax:
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State or County License. N'f' 6E—:1''1933
If valNe of construction is $2500 or more, a RECORDED Notice of Commencement is required.
o UPPLEMENTAL CONSTRUCTION LIEN LAW:JNFORMATION
DESIGNER/ENGINEER: _ Not Applicable
MORTGAGE COMPANY: _ Not Applicable
ame:
Name:
Address:
lddress:
'pity: State:
!p: Phone
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City: State:
Zip: Phone:
SIMPLE TITLE HOLDER: _ Not Applicable
BONDING COMPANY: Not Applicable
Name:
ddress:
Name:
Address:
ty:
2�p:
City:
Zip: Phone:
Phone:
O 1 NER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I c rtify 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
whi' h is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
str cture. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration o of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in a cordance 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,
acc�Issory 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
imlillrovements to your property. A Notice of Commencement must be recorded and posted on the jobsite
bef l re the first inspection. If you intend to obtain financing, consult with lender or an attorney before
com, mencin .work or recording our Notice of Commenceme .
I_'A
Sigature of Owner/ Lessee/Contractor as Agent for Owner
'Signature of Contractor/License Holder
STATE OF FLORIDA
C LINTY OF
STATE OF FLORIDA
COUNTY OF \fib s0 e J
Th forgoing instrument was acknowledged before me
thi day of Jv v 2016 by
The forgoing instrument was acknowledged before me
this kR day of 20AS by
Per
Name of person making statement
ovally Known �— OR Produced Identification
Name of person making statement
Personally Known_ OR Produced Identification
Type
Pro
of Identification
uced
Type of Identification
Produced
(Sig
ature of Notary Public- State of Florida)
(Signatur of Notary Public- State of Florida )
Co
ission No. �'iJ++�'(R�'�1""'�"
f,,• RACHELD.PATTERSON
_�. Commission # GO 204186
•�'4?0,•;(:'�
Commission No.0 �...,.
a* n. RACHELD.PATTciiSON
'N; Commission # GG 204165
RE IEWS
FR
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800.385•T019
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Insurance 800.385.7019
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DAT
REC IVIED
DAT
CO PLETED
Rev. 8
2/17