HomeMy WebLinkAbout0703-0320-APPLICATION FOR BUILDING PERMIT CERTIFICATE OF CAPACITYOFFICE USr .
DATE FII )3c Cam'
PLAN REV' EW FEE: RECEIPT NO.. PERMIT NUMBER:
CONC NCY FEE: RECEIPT NO.: CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED
St. Lucie County Building and Zoning
2300 Virginia Avenue
Ft. Pierce, FL 34982-5652
772-462-1553
APPLICATION for BUILDING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION:
1.
LOCATION/SITE ADDRESS: �� \�� R'L1 1J���i,��1�
2.
S/D NAME: W60aRlL 0%NA SITE PLAN NAME:
3.
i PROPERTY TAX ID #:
4.
LEGAL DESCRIPTION (attach extra sheets if necessary):
5.
I PLAT 6. PAGE 7. BLOCK
I BOOK_ NO. NO.
8. LOT
NO.
p
ka
� 17 q- ?5444 x
(oq,28
9.
7 �..Y
PARCEL SIZE: ACRES/SQ FT. 10C2 LOT DIMENSIONS Sty, �
_ 7
6
00
10.
DESC TION O CONSTRUCTION PROJECT OR WORK ACTIVITY:
11. SETBACKS , ACTUAL FRONT: CK: / RIGHT: LEFT:
SIDE SIDE
12., TYPEOF CONSTRUCTION (Check all appropriate boxes)
i
CONSTRUCTION [ ] EXPANSION/ADDITION [ ] INTERIOR RENOVATION
��rsl ENTIAL [ ] COMMERCIAL [ ] INDUSTRIAL
I [ ] OTHER (SPECIFY)
DESCRIPTION OF PROPOSED
Sq. Ft./CONSTRUCTION: 0 ®® 15. Sq. Ft. 1 st Floor:
VALUE OF CONSTRUCTION: $ �s��� ' o
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
e 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
;ORDED Notice of Commencement must be submitted with this application.
SLCCDV Form No.: 001-02
OWNER INFORMATION
NAME: IIII S�-IL % ) Q �,,,',,1_- 1 '_
ADDRESS: O Z I i t C..1� -� ee- L 1-
CITY. STATE: L ZIP
PHONE (III AYTIMATAC" � email:
IF THE l l E SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED ABOVE, PLEASE
FILL IN Ili AME AND ADDRESS BELOW.
FEE SIMPLE TITLEHOLDER:
BI
ADDRESS:
CITY:.III STATE: ZIP
YTIME):
CONTRACTOR INFORMATION
ST. of P L REG./CERT #: �C / 3 % 2 161 ST. LUCIE COUNTY CERT #:
Ess:
y"`Fns STATE: ZIP 32 z.;
E (DAYTIME): FAX NO. email:
STATE:
dE (DAYTIME): L
DING COMPANY:
DUCK.
STATE:
LENDER:
ZIP
ZIP
TY: STATE: ZIP
RPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification
will be voided and returned to you by mail.
i
CERTIFICATION:
This applic'lion 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 bperformed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
may be req ired for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS,
AND AIR'il ONDITIONERS, ETC., not otherwise included with this building permit application.
The follo I'ng 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.
OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO
OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
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.
'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance
with all applicable laws regulating construction and zoning.
CONTRACTOR SI AICONTRA(fTOR—SIGNATU
STA OF FL
COUNTY OF
The foregoing instrument was acknowledged
efo%te me thi cr>3day of T'rC 20p-3 by
who is personally
kno n t me or who has produced
1I� - VC"%Q., V%. as identification.
of Notary
or Print Name of Notary
No.
�n e6''•, STELLA M. HUNTER
Y COMMISSION # DD 630775
,•= EXPIRES; January 23, 2011
Bonded Thru Notary Public Underwdtere
STATE OF FLOJUVA
COUNTY OF N\ - `mcA e_
The foregoing instrument was acknowledged
before me thisQQday of L� , 200 by
who is personally
know o me or who ha oduced
as identification.
Signature of Notary
STEL A M. HUNTER
yP ISSION�D5"6m5
T e or Print a' `1 o'PIRES; January 23, 2011
'�,ilf Boned Thru Notary Public underwriters
Commission
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.
or specific instructions see appropriate permit checklist.