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All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date: I/Z 1 / l(> SCANNED Permit Number:
BY
St. Lucie Counfit
RIF/C`FR.'ED
Building Permit Application NOV 0 12016
Planning and Development Services
Building and Code Regulation Division PER;AHTTING
2300 Virginia Avenue, Fort Pierce FL 34982 St. Lucie County, FL
Phone: (772) 462-1553 Fax: (772) 462-1578 Commercial) Residential
PERMIT APPLICATION FOR: N�u I 1�;S f,-P S
Address:
Legal Description:
Property Tax ID #: cL? I ' �-10 000 6 Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
Aaaitionai work to oe perrormeo unaer tnis permit— cnecK an mar apply:
_Mechanical _Gas Tank -/asPiiping, _Shutters
_ Electric _ Plumbing _ Sprinklers _ Generator
Total Sq. Ft of Construction: i ,Sq. Ft. of First Floor:
Cost of Construction:$ :-+OUUtilities: _Sewer _Septic
Windows/Doors
Roof
Building Height:
WME LESSEES
COT TR as :
Name _ .,nr.L
5St. L�v, 60W4 /
Name r S . Jo�hSOI� i
Address; _19,90 "t4" d=`rQJG
Com an
p y:tr�lv-fs.{-o,Ol.e'r". �ot;nSd,n
Addfess:
_
State:
Zip Code: 3ti"l 9&7 -- Fax:
Phone No.
City: R: to'7'E� Stater
Zip Code: 3't`I H-7 Fax:
Phone No(77Z) TOt-30!3
E-Mail:
Fill in fee simple Title Holder on next page ( if different
from the owner listed above)
E-Mail
State or County License 2Z,? 6 6
If value of construction is 2500 or more, a RECORDED Notice of Commencement is required.
DESIGNER/ENGINEER:
Name:
_ Not Applicable
MORTGAGE COMPANY: _ Not Applicable
Name:
Address:
Address..!"
City:
Zip: Phone
State:
City: State:
Zip: Phone:
FEE SIMPLE TITLE HOLDER:
Name:
_ Not Applicable
BONDING COMPANY: _Not Applicable
Name:
Address:
Address:
City:
City:
Zip: 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 no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in conflict with any applicable Home Owners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Home Owners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all respects, perform the work
in accordance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full.concurrency review: room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory uses to another non-residential use
WARNING TO OWNER: Your failure to Record a Notice of Commencement may result in your paying twice for
improvements to your property. A Notice of Co encement must be recorded and posted on the jobsite
before the first inspection. If you intend to oeta' i financing, consult with fender oran attorney beforeA
Signature
STATE OF FLORIDA _ STATE OF FLORIDA
COUNTY OF COUNTY OF
Holder
The forgoing instru nt was acknowledged before me The forgoing instrum nt was acknowledged before me
this I day of �=n\ 1 20�pby this�dayof�J20JJ'pby
(Signature of Notary Public- State of Florida
Personally Known OR Produced Identification
Type of Identification
Produced ,°'.... KAREN S. NIELSE
IT4
Commissiopq FF 1151
a�•v My
Commission No.. 1 1�( aoq��o�F (Seal)Commission Exii
r,,,, ,,o June 12, 2018
(Signature of Notary
Personally Known
xvae of Identification
r State of Florida I
OR Produced Identification
mission No. _
........... KAREN S. NIELSEN
Commission a FF 115
3
= (Wgl¢ommission Expi
%�a 'June
e
n°r 12. 2018
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