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PLAN REVIEW FEE: RECEIPT NO.: IA I �_ PERMIT NUMBER:
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ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED
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St. Lucie County Building and Zoning
2300 Virginia Avenue
• OR10Q • . Ft. Pierce, FL 34982-5652
772-462-1553— C
APPLICATION for -BUILDING PERMIT
CERTIFICATE of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION "" 1 L�
LOCATION/SITE ADDRESS:. ' T I(., OA P S L a, 1
S/D NAME: T . L U C I f . 6PjAQ�5 SITE PLAN NAME:
PROPERTY TAX ID #:
LEGAL DESCRIPTION (attach extra sheets if necessary): !J 1 (a t O ",sr Y2 o YG LO T 7
PLAT 6. PAGE 7. BLOCK 8. LOT
-'BOOK NO. NO. NO.
PARCEL SIZE: ACRES/SQ FT. C LOT DIlVIENSIONS . Rt5x
10. ' 'DESCRIPTION OF CONSTRUCTION PROJECTOR WORK ACTIVITY:
fz6-5TC)4.j CA-
r 14�•�� IJo� ��.'
11. SETBACKS (ACTUAL) FRONT: Z BACK: RIGHT: r LEFT: p
l� SIDE SIDE
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
NEW CONSTRUCTION. [ ] -EXPANSION/ADDITION [ ] INTERIOR RENOVATION
RESIDENTIAL [ . ] COMWRCIAL [ ] INDUSTRIAL.
] OTHER (SPECIFY) -
13. DESCRIPTION OF PROPOSED USE: s !.ti%�&k Apmf 4. /,Ds;j C/,
14. Sq. Ft./CONSTRUCTION: 3771 15. Sq. Ft. Ist Floor: '37 71
16. VALUE OF CONSTRUCTION: $
The.value of construction_is used to determine the'amount.of permit fees to be. assessed. St. Lucie County reserves the right to question arid/or,modify the indicated
value.of construction if it is demonstrated that the submitted figures, are not consistent with similar types of constriction activities: If the value is $2500 or more,.a
RECORDED-Noiice-of Commencement must -be submitted with this application.
SLCCDV Form No.: 001-02
OWNER INFORMATION
V
NAME: Jq L%iz12 .'- Ld /Z- I 6A l T 7__h
ADDRESS: 2 5 ® % 59 WOLS T
CITY: Po/v : J _ LUCC4, STATE: ZIP 3 Qcj 5 2—
PHONE (DAYTIME):- - ?Z 6 i - > 7 7-/ -email &J 5,AI-Tr6I'
IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED ABOVE, PLEASE
FILL IN NAME AND ADDRESS BELOW.
FEE SIMPLE TITLEHOLDER:
ADDRESS:
CITY
PHONE (DAYTIME):
STATE:
ZIP
CONTRACTOR INFORMATION ® &Jt312Q.- (bO l C b�z,1Z_,
ST. of FL REG./CERT #:
BUSINESS NAME:
QUALIFIERS NAME: _
ADDRESS:
CITY:
PHONE (DAYTIME):
STATE:
FAX NO.
ST. LUCIE COUNTY CERT #:
ZIP
email:
ARCHIT/ENGINEER: _ Qy ns a t f bAe 'J 4-A
ADDRESS: 232¢ %yntb►2�, �Q .
CITY: O%ZA�,-J,0 6 STATE: P(- ZIP D2_6
PHONE (DAYTIME):
BONDING COMPANY:
ADDRESS:
CITY: STATE:
ZIP
MORTGAGE LENDER: 4&/Z6CVL
ADDRESS: 3.8 % 5 r/ca0 6A&_,_
CITY: Shy A'►2 % STATE: je�- C__ ZIP 3 C) 194t
IMPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification
it will be voided and returned to you by mail.
CERTIFICATION: 7�
This application 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 be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits
may be required for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS,
AND AIR CONDITIONERS, ETC., not otherwise included with this building permit application.
The following 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.
NOTICE TO 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.
NOTICE 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.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance
th all applicable laws regulating construction and zoning.
OWNER/ O OR SIGNATURE CONTRACTOR SIGNA
STATE OF FL"'I'l 1 /
COUNTY OF I.�t
The foregoing ms ent w s acknowled ed
before me this =y of , 20C�by
via 1 .1'Ad i-19-GL , who is personally
known to me .or w as +poduced
as identification.
Type or Print Name
tieatriz Serrano
Commission #DD228304
Expires: Jul 01 2007
Bdnded Thru
Atlantic b6ndina.rn Y.
STATE OF FI
COUNTY OF
The foregoing inq6urtent was acknowledged
before me this day of , 20__, by
who is personally
known to me r who has produced
as identification.
of Notary
or Print Name of Notary
Commission No. (Seal) :/ Commission No. (Seal)
NOTE: 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.
For specific instructions see appropriate permit checklist.