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1LL APPLICA XVJNFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED I fQ y 0
Date: J I Permit Numt M.E
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Building Permit Applicatio
Planning and li evelopment Services Permitting Department
Building and ode Regulation Division fitLucie I e �- U n t 1= L
2300 Virgin , venue, Fort Pierce FL 34982 y,
Phone: (77 462-1553 Fax: (772) 462-1578 Commercialre-s—ld—entidl
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PERMIT AlPLICATION
FOR: To Select from dropbox, click arrow at the end of line
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ress:
iertyTax #: 5b2- _ O l - 04IT - 000
Plan Na .
Lot No.
Block No.
Setbacks F ont Back: Right Side: Left Side:
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.€554 aii'..`',R`�`sx�' t✓_-k.�1G`. - ` iti.r r.n _ K
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itiona wo rK to tie e orme under tispermit-checka apply:
HVAC Gas Tank ❑Gas Piping _ Shutters Q Windows/Doors
IJ
1-1 Electric r-] Plumbing Sprinklers 0 Generator 0 Roof Roof pitch
Total Sq. Ft ol Construction: Scl. Ft. of First Floor:
Cost of Const ction: $ Utilities: 11 Sewer Septic Building Height:
10
Name
Address: A9
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NfMol, %LUDCompan
Name: ad
City: e
Zip Code:
State:
1 Fax:
Address:
City: ry. . State:
hone No.
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Zip Code: Fax:
E-Mail-
Fill in fee sim
Phone No. -
E-Mail:
Pie Title der on next page ( if different
from the Ow
er listed above)
State or County License: P 9-4 q SS
value of con ruction is $2500 or more, a RECORDED Notice of Commencement is required. �(� � U
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DESIGNERNGINEER:
Name:
Address:
City:
Zip:
_
Not Applicable
MORTGAGE COMPANY:
Name:
Address:
City:
Zip: Phone:
Not Applicable
State:
1
State:
Phone
FEE SIMPL
Name:
Address:
City:
Zip:
TITLE HOLDER: _
Not Applicable
BONDING COMPANY:
Name:
Address:
City:
_Not Applicable
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 nlb work or installation has commenced prior to the issuance of a permit.
St. Lucie Couni makes no representation that is granting a permit will authorize the permit holder to build the subject structure
Which is in con lict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Pleaa consult with your Home Owners Association and review your deed for any restrictions which may apply.
In considerati °i of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in accordance vith the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following uilding permit applications are exempt from undergoing a full concurrency review: room additions,
accessory stru tures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
WARNINGf
OWNER: Your failure to Record a Notice of Commencement may result in your paying twice for
improvemes to your property. ANotice of Commencement mustbe recorded and posted on the jobsite
before the ftinspection.Ifyouintend toobtain financing, consult with lenderoran attorney before
rnmmncinwnrk nr recording veur Notice of Commencement.
Signature of wner/ Lessee/Contractor as Agent for Owner
Signature of Contractor/License Holder
STATE OF FLORIDA
STATE OF FLORI�A
COUNTY , � r� a
COUNTY OF
Instrument
The forgoing was cknowledged before me
this da of ifl 20 by
The for oing instru ent was acknowledged before me
this day of a' 2jjby
Nar
le of person making statement
Name of person making statement C�
Personally K
own OR Produced Identification
Personally Known OR Produced Identification
Type of Iden
i ifi ,ation
Type of Identifica0bri
If
Produced
Produced
(Signa r o
N ry Publ' - t of cif L BYRNES
ign of No lry Publ'c- to f Florida )
NOTARY PUBLIC
TIFFANY L BYRNES
Commission
STAfE* FLORIDA
Commission No. NdWl) PUBLIC
Comm# FF967191
STATE OF FLORIDA
•Expires 312J2020
• Corral FF967191
Expire;
3/212020
REVIEWS
FRONT
ZONING
SUPERVISOR
PLANS
VEGETATION
SEATURTLE
MANGROVE
COUNTER
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
REVIEW
DATE
RECEIVED
DATE
COMPLETE
Rev. 8/2/17