HomeMy WebLinkAboutBUILDING PERMIT AFFIDAVITALL A PLICABLE INFO MUST BE COMPLETED FOR PPLICATION TO BE ACCEPTt
Date 6'j Permit Nu!nber:
RECEIVED
Building Permit Application
Plan1 ng and Development Services AUG 1 2018
Build, g and Code Regulation Division
2300 firginia Avenue, Fort Pierce FL 34982 _ ST. Luria County, Permitting
Moir: (772) 462-1553 Fax: (772) 462-1578 Commercial Residential
PER
IT APPLICATION FOR: To Select from dropbox, click arrow at the end of line
PRO,
OSED IMPROVEMENT LOCATION:
Addre s: Cl 0 POI NXA1qPA �� ark -vim I PL 3q9 1 it y�� 1
Legal escription: LIB\\ kof3 /�IQ1SZE CVP�Z> C�U'Z2,Y CW6 1
PropeityTaxID#: /335/—�SoZ-��y-�-9 Lot No.
Site PI In Name: �'�[oµh�'AZI� C.'a a/." Ntlet Gv. Block No.
Projec Name: C3L'As��
Setba ks Front Back: Right Side: Left Side:
PET DESCRIPTION:Of WORK'.
� C��i�.l�tiair� O� Sr�ast✓��cu� �� iBnv,e�,
�3ST)we►w 0, eo r- C9-
CON 'TRUCTION INFORMATION:
Additi 3yAl work to oreie ormed un er t is permit - c ec a11 apply:
OF
V C Tank ❑Gas Piping _ Shutters ❑ W' dows/Doors
_ Di
Ei P 71u m b 1 ng Sprinklers ElGenerator ` Roof ® Roof pitch
Total q. Ft of Construction: t5 � A � S . Ft. First Floor: (P1z�
Cost o Construction: $ -2 16,&C C:> Utilities: lZewer El Septic Building Height: dam`
OW .
ER/LESSEE:
CONTRACTOR: 2009ellr C�j<
Name
Addre'
City:
Zip C
Phone
E-Ma
Fill in
from I
vd'& US S Q
Name: jAaAt _caetS , _'rxje..d
Company:
Address: At1(oa PW 9_Ve
City: ��46r14M-l4�- State: R_
Zip Code: 3q /p Fax: _ig' 973-6d*4
Phone No. %9- S-73 . /1;109
E-Mail: PZC-F'As 4 (z 1-r0 om
State or County License: CG-r— ® 4993i1-
s:'QW0 V-NF— �'-�"Clt S I 11't'1- J-
0- LAO)�DiRD'� State: �L
de: 333®eeT Fax:` IM 8`i3dfo
No. q3r4� bs'' Q 190 8'
:
I ee simple Title Holder on next page (if different
a Owner listed above)
if vaiugj of construction is $2500 or more, a RECORDED Notice of Commencement is required.
SUP
;LE,MENTAL CONSTRUCTION LIEN,LAW INFORMATION:
DESI
Nam
Add
City:
Zip:
.NER/�E�GINGIINE R:. Not Applicable
4- 82AD&O A) A, IPA
MORTGAGE COMPANY: — Not Applicable
Name:
Address:
City: State:
Zip: Phone:
ss: i_QC-i7 Vf-
UpC� State:
Phone ii9L- al—� S
FEE
Nam
Addyss:
City:
Zip:
SIMPLE TITLE HOLDER: _ Not Applicable
:
BONDING COMPANY: _Not Applicable
Name:
Address:
City
Phone:
Zip: Phone:
OWN R/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I certi that no work or installation has commenced prior to the issuance of a permit.
St. Luc! County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which ! in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structu Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In cons'"eration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in acco:ance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The foll wing building permit applications are exempt from undergoing a full concurrency review: room additions,
accessc structures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
WARt ING TO OWNER: Your failure to Record a Notice of Commencement may result in your paying twice for
impro' ements to your property. A Notice of Commencement must be recorded and posted on the jobsite
befor the first inspection. If you intend to obtain financings, e0' ult with lender or an attorney before
comet ncina war recording vour Notice of Commence a i, A
as Agent for Owner I Sign
STAT, OF FLORIDA STATE OF FLORIDA
COU, TYOF 'ST• o-)CIIF- COUNTY OF LLX-4r'
The ft,r i g instrument was acknowledged before me
ti, Imlay of M W!' . 20A by
K LAu-5
Name of person making statement
Perso ally Known OR Produced Identification 2<-10'
Type f Identification
Prodt6d lc�10A 'DOVE , %C4�5AJ*__
(Sign ture of Notary Public-
qpffo p Notary Public State of Florida
Com ission No.f* I&S�i7 y=° (Be�S Rost
oeftio Expires 2/23/2018185297
REV
RECE VED
DATE
COM LET
Rev. 8/ /17
The for ng instrumtt acknowledged before me
this ay ofy . 2019 by
Name of perso ,;raking statement
Personally Known 1/ OR Produced Identification
Type of f enti (cation
Produced
of Notary Public- ale j;,�(oN61tly Public State of Florida
Brian S Rost
1 NO. �gs�i� c r �lnlssion FF 185297
on rwo ' 6xglra• 12/23/2010
FRONT I
COUNTER ROEVIEW S REVIEWOR I RE EW I VEGETATIREVIEW EWON I s EV EWLE I MAVIEWOVE