HomeMy WebLinkAboutAPLICATION FOR BUILDING PERMIT CERTIFICATE OF CAPACITYSCANNED
I✓ USE_ONLY: t'. ude coun�y
FILED: ,
REVIEW FEE: RECEIPT NO.: q� T PERMIT NUMBER: J
URRENCY FEE: -�� ,� RECEIPT NO.: CERT. CAP. NO.:
ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED
ap PLANNING & DEVELOPMENT SERVICES DEPARTMENT
BUILDING & CODE REGULATIONS DIVISION
2300 Virginia Avenue
Ft. Pierce, FL 34982-5652 ,1!J
10 772-462-1553 /(
APPLICATION for BUILDING PERMIT 4.
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJFaCT INFORMATION _ L-----
1. LOCATION/SITE AD RESS: I 1 s ' ®I{ � 3
2. PROJECT NAME: SITE PLAN NAME:
3. PROPERTY TAX ID #: 14 is - 10 ®® - '-"'> P
4. LEGAL DESCRIPTION (attach extra sheets if necessary): e \JieZ o itl
5. I PLAT BOOK 6. PAGE N 7. BLOCK NO. 8. LOT NO.
9. PARCEL SIZE (ACRES/SQ FT.): LOT DIMENSIONS:
10. COMPLETE D CRIPTI N OF CONST ACTIVITY:
�fez
11. SETBACKS (ACTUAL) FRONT:_ BACK;. RIGHT SIDE: LEFT SIDE:
12. TYPE OF CONSTRUCTION (Check all appropriate boXT5
6
NEW CONSTRUCTION [ ] EXPANSION/ADDITION [ ] INTERIOR RENOVATION
[ ] RESIDENTIAL [ ] COMMERCIAL [ ] INDUSTRIAL
[ ] OTHER (SPECIFY)
13. DESCRIPTION OF PROPOSED USE:
14. SQ. FT OF CONSTRUCTION: ';'52 ® 15. SF. `F)L FLOOR:
16. I VALUE OF CONSTRUCTION: $ ZI—Ifj
The 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
value 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
RECO ED Notice of Commencement must be submitted with this application.
Form No.: 001-02
UPDATED 6/25/09
ER INFORMATION
PH NE (DAYTIME):Mt Email:
IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FF
FIL11 IN NAME AND ADDRESS BELOW.
FE II SIMPLE TITLEHOLDER:
AD RESS:
i
(DAYTIME): (_)
C 'NTRACTOR INFORMATION
ST. f FL fn�
REG.CERT #:
BUSH SS NAME: o` o t _ �►f1'
(DAYTIME):
(DAYTIME): q14 - 4 `1 1
JG COMPANY:
SS:
STATE:
_ STATE:
® ?40 FAX NO.
STATE:
S
0
THE OWNER LISTED ABOVE, PLEASE
��S,,TT./. LUCIE COUNTY CERT #:
<Ae
ZIP:
01,67 Emai1:.7 &
ZIP:
CIT II STATE: ZIP:
MORI'I GAGE LENDER: 'N
ADD SS:
CITY E STATE: ZIP:
IMP RTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification
it wi „ be voided and returned to you by mail.
C R. FICATION:
Thi 11 application is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate of capacity,
if a plicable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit and that all
wolk will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
ma �I, be required for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS,
AN AIR CONDITIONERS, FENCES, ETC., not otherwise included with this building permit application.
St. I ucie County makes no representation that its granting of a permit will authorize the permit holder to build the subject structure
whi , h is in conflict with any applicable Homeowner Association rules, bylaws or any covenants that may restrict or prohibit such
stru ure. Please consult with your Homeowner's Association and review your deed for any restrictions which may apply.
following building permit applications are exempt from undergoing a full concurrency review: room additions, accessory
tures (all types), swimming pools, fences, walls, signs, screen rooms, utility substations & accessory uses to another non-
ential use.
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 YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
TO APPLICANT: IF IT IS NOT YOUR RIGHT, TITLE, AND INTEREST THAT IS SUBJECT TO
ATTACHMENT: AS A CONDITION OF ISSUANCE OF THIS PERMIT, YOU PROMISE IN
GOOD FAITH TO DELIVER A COPY OF THE CONSTRUCTION LIEN LAW NOTICE TO
THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT.
SIGNATURE
OF FLORID
'Y OF A ,U?/ Al
The loregoing�rument was acknowledged before
me tis 3L day of 4J 20 -13 ,
i
by
who @1 personally known ' or has produced
identification.
STATE F FLORIDA,,,,//)) _ )
COUN OF i79,# i
The foregoing instrument was acknowledged before
me this t' day of j4 �% , 20 l ,
by J 6 o 0
who is personally known I)-- or has produced
of Notar/9 - % (/ Signature of Notary
as identification.
No. Z) 1,5 (Seal) Commission No. 6f 6 966 (Seal)
AUDREY K. i
TWO (2) M. ACH SIGNATURE MUST B R
THIS BUI g .h- UILDER, THE OWNER MU Y : S N
THIS AP F .. It 43I® D ON THE FRONT OF THI A I11uTmyFalnlnswarae800385-7019
OWNER BUILDER AFFIDAVIT WILL QUIRED FOR ALL OWNEItl
For "pecific instructions see appropriate permit checklist.
AUDRE'� K. K ::�RCZAK ?9 'r& _ AU R EY �mis,
= sir.
p
or Expires July 6, 2015 `
i °@01?dBdThN��97F2If�1:I51it911C88(iO.3BSd019 "''n°09�„�_....
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