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F-AllPPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED ��'
Date: �. Permit Number: v.��_OC `7
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-- - -- -- - - - - Building Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce FL 34982
Phone: (772)462-1553 Fax: (772)462-1578 Commercial Residential
PERMIT APPLICATION FOR: f �C�- -�CGL-,k
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Legal Description:
Property Tax ID#: ,� ,3� b —CY�� l,I—'d430 Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
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Additional work to be performed under tis permit—check all that appy:
_Mechanical _Gas Tank —Gas Piping _Shutters _Windows/Doors
Electric _Plumbing _Sprinklers _Generator _Roof
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Cost of Construction:$ , Loa ✓ Utilities: —Sewer —Septic Building Height:
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City: �o rfi rre rCr State:_ ,Address: r- E"C( ffa C,b0/ & iye
Zip Code: Fax: r`v 6 e ete A State:___Fa_�r
Phone No. 7 7 Z- R"R'Z- DZip Code: 12-2 A . Fa/x:
E-Mail: Phone No.7 7,Z ,YO—0 b y1
Fill in fee simple Title Holder on next page ( if different E-Mail: ,IL y 9 0 t &,6 L r C0X4-
from the Owner listed above) State or County License: e C 17 y D Q2_2
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of construction is 2500 or more,a RECORDED Notice of Commencement is required.
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DESIGNER/ENGINEER: _Not Applicable MORTGAGE COMPANY: _ Not Applicable
Name: Name:
Address: Address:
City: State: City: State:
Zip: Phone: Zip: Phone:
FEE SIMPLE TITLE HOLDER: _Not Applicable BONDING COMPANY: Not Applicable
Name: 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 Commencement must be recorded and posted on the jobsite
before the first inspection. If you intend to obtain financing, consult with lender or an attorney before
commencing work or recording our Notice of Commencement.
Signature Owner/Agent/Lessee Signature of ontractor/License Holder
STATE OF FLORIDA STATE OF FLORIDA ,
COUNTY OF _�;A "c _Q COUNTY OF : rA7 ,U,�s
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this L day of '(rGu. 20_ by thisJI_day of �Qv. 20]� by
�Osi a
(Name of per n acknowledging) (Name of pe on acknowledging)
(Signature of Notary Public-Stat of Florida ) (Signature of Notary P lic-State of Florida)
Personally Known OR Produced Identification Personally Known OR Produced Identification
Type of Identification Produced Type of Identification Produced
YrL�o•�"1•�e1•I�S'�
Commission No. u � (Sb®$ AHNAINGRAM �ssndieto euogeNy nagt apuog . I
Commission No. .��°'i'O��d•
PubliC-state of Florida t 4A U01 Itl}Ii10'J
• Notary 0,20 I
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_ Comm.Expires Dec 2
Comm”,sio •��
';�, Votary Ass tlHOM VNHVI!SVI
REVIEWS FRON Nl i edthra h PLANS VEGETATI N A—T-b'fTL• '— MANGRO
COUNT, �R" `IL� REVIEW REVIEW REVIEW., REVIEW REVIEW
DATE
RECEIVED
DATE
COMPLETED
Rev.