HomeMy WebLinkAboutBUILDING PERMT APPLICATIONOFFICE USE ONLY:
BP #: %b 6 /(o PLAN REVIEW FEE: l D 90 RECEIPT NO.: I ygkPERMIT NUMBER:
CONCURRENCY FEE: RECEIPT NO.: CERT. CAP. NO.:
OFFICE :USE ONLY:
ALL INFO MAST BE COMPLETE 8t FILLED IN TO BE ACCEPTED-
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SECTION:
TOWNSHIP:
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LAND USE:
LOT CVG %:
TAZ NO.:
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MAX HGT`
CST TYPE:
OCCP TYPE:
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MAX. OCCP:
# OF FLRS:
WATER:
SEWER:
SPRINKLERS
STORMWATE
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LOT OF REC (befr 1190)
LOT OF REC (aftr 1190)
LOT SPLIT
LOT SPLIT
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11
INITIALS
ST. LUCIE COUNTY PUBLIC WORKS
BUILDING & ZONING DEPARTMENT
2300 VIRGINIA AVENUE
'20R10 FORT PIERCE, FL 34982-5652
• . °� 561-462-1553 G(�L
_S0'0_.
APPLICATION for. BUILDING PERMIT
CERTIFICATE. of CAPACITY/ZONING COMPLIANCE
PROJECT INFORMATION
1. LOCATION/SITE ADDRESS: A2 l 'Sou"r,l MA2K,ET AVE
2. S/D NAME: SITE PLAN NAME: N�p►
3. PROPERTY TAX ID #: i6oi bo-5lo O 00
4. LEGAL DESCRIPTION (attach extra sheets if necessary):34•355'4DE WLLEWIS 5/t7 Ft za m 74Le 5E C0 - LOT'Cj
t2.vr► w 2to5�i -kD 114 con-t w Iatch. Ck FTIW N no p'r,T41 E M9-19 FTI TH S 15o FrTH
2-5 F"f t 7i1 5 180 FT TO P 0 M 1LFS6 N IZ Fr A 5 tDnT %tiV4e 0" "r^X MDL+�
5. PLAT 6. PAGE 7. BLOCK 8. LOTS`
BOOK NO. NO. NO.
9. PARCEL SIZE: ACRES/SQ FT. 138 Ac rEs LOT DIMENSIONS 10A.gX I BOX259138X IxiI�1X3i�
1 b. DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTIVITY: cotnsT VvcT o h c)F
Two i 1rltglr SP,e►s (0FFle� s 5T�1�i�i
11. SETBACKS (ACTUAL) FRONT: ' BACK: RIGHT EFT
SIDE SIDE:
12. TYPE OF CONSTRUCTION (Check all appropriate boxes)
[ ] NEW CONSTRUCTION [ ] EXPANSION/ADDITION INTERIOR RENOVATION
[ ] RESIDENTIAL [ ] COMMERCIAL [ ] INDUSTRIAL
[ ] 4
OTHER (SPECIFY)
13. DESCRIPTION OF PROPOSED USE: lDl F omu FFICF
�
r� aa u Ft. �
14. Sq. FtJCONSTRUCTION: (coo 15. q. st Floor. 3�
16. VALUE OF CONSTRUCTION: $ 2 o000
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 moditrui
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 5250C
or more, a RECORDED Notice of Commencement must be submitted with this application.
SLCCDV Form No.: 001-02
041
OWNER INFORMATION:
NAME:
ADDRESS: 4Z% 5. �►�K-�T AV
-STATE: FL - _-L - -- - = zip
PHONE (DAYTIME): I77Z)
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):
CONTRACTOR INFORMATION
STATE: ZIP
ST. of FL REGJCERT S: ST. LUCIE COUNTY CERT fit:
BUSINESS NAME: C)w u QY dU 1 ` 1 oer-
QUALIFIERS NAME:
ADDRESS: �2"7 �e "' A►-KeT A
CITY: + `1r STATE: ZIP Mq82
PHONE (DAYTIME): 72-4 4bq 90 ap4 FAX NO.
ARCHITIENGINEER: AyIn«4e4 § Cntd
M"pt, T-kX ,
ADDRESS: 100 AVE At Ss L SE -
CITY: i=o,--r erc -p STATE: F- ZIP q s�
PHONE (DAYTIME): 1772f 4�P4 -Set 0 FXX 77Z- - O 44
BONDING COMPANY: NA .
ADDRESS:
CITY: STATE: DP
MORTGAGE LENDER: NA .
ADDRESS:
CITY: STATE: ZIP
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:
This application is hereby made to obtain a permit to do the work and installations as indicated, and to obtain a certificate o-
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
with all applicable laws regulating construction and zoning.
OWNER/CONTRACTOR SIGNATURE CONTRACTOR SIGNATURE
STATE OF FLORID_ STATE OF FLORIDA
COUNTY OF COUNTY OF
The foregoing Instru ent as acknowledged
before me this � day of , 20Qfby —
who "s pefsonal kn n to me or who
has Droduced, - y _ a identfica— identification.
Signature of otaryTJ
Type or Print Name of Notary
Notary Public Title
Commission Number
The foregoing instrument w acknowledged
before me this day of 20 , by
who is rsonally known to me
or who has produced as identification.
Signature of No
Type of Pd* Name "of, Notary
Title
Commission Number
(seal) Diane R. Flanigen (Sea)
MY COMMISSION # DD065504 EXPIRES
/
a October 16, 2005
E FI'rr o;> BONDED THRU TROY FAIN INSURANCE, INC.
NOTE: TWO (2) SIGNATURES ARE REQUIRED. EACH SIGNATURE MUST BE NOTARIZED.
IF APPLYING FOR THIS BUILDING PERMIT AS AN OWNER/BUILDER, THE OWNER MUST PERSONALLY APPEAK
TO SIGN THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THIS APPLICATION.