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ALL APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED r 11
Date: Permit Number:
e
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: To Select from dropbox, click arrow at the end of line
PROPOSED INI0" ' MENtLOCATION ' '"
Address: A
Legal Description: -
Property Tax ID#: 'Agae --Coo - a Lot No.
Site Plan Name: \ \, Block No.
Project Name: Ub'_ CNy&( c (�a\_IeQ
Setbacks Front Back: Right Side: Left Side:
DETAILED DESCRIPTION".OF WORK
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CONSTRUCTION INFORMATION-
Additional
NFORMATIONitiona work to be a orme under this permit-c ec a apply:
HVAC E]Gas Tank ❑Gas Piping _Shutters Q Windows/Doors
11 Electric Plumbing 0Sprinklers E Generator 1:1Roof
Total Sq. Ft of Construction: SFt.of First Floor:
Cost of Construction:$ C)3�0L Utilities: _Sewer ElSeptic Building Height:
.OWNER/LESS'EE: :`CONTRA :OR:
Name ��Ca ngName: 1.6Lu u (wk
Address: a _L,(- Company: ,`
City: (� rS,Qf State:l�\\ Address: O
Zip Code:����Fax: City k ,�� � b'�� State V-L
Phone No.1-1�- ?�-��('�� Zip Code: Fax: n11`A 3LW') `2y I-S
E-Mail: Phone No._�.)a-?>q4U-S43�
Fill in fee simple itle Holder on next page(if different E-Mail: v c,
from the Owner listed above) State or Co my License:
If value of construction is$2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN1AW INFORMATION:{
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:
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,copplt with lender or an attorney before
commencing work or recording our Notice of Commencement)
� ��di s
_Signature of Owner/Lessee/Agent /Signature'f Cofitractor/License Holder
STATE OF FLORI�D�,44 � STATE OF FLORI P_A
COUNTY OF- -`,5L1�(` cC COUNTY OF .�L� i WtLt
The fU ing instrt was acknowledg�j efore me The forgoing instr menet w s acknowledged fore me
thisday of 20 I_-) by this 2A day of LX20 Z by
(Name of person acknowledging) (Name of person acknowledging)
(Signature of Notary Publc-Stat (Signature of Notary P c-St a of Florida)
Personally Known v OR Produ��d I n Personally Known office
Type of Identification Produced 'O Type of Identification rs "` HO �
MY COMMISSION#EE854297
Commission No. ( O$��p�'f� Commission No. '9• ... 't' EXPIRfivary 08,2017
� (407)393.0153 FloridallotaryService.com
Revised 07/15/2014 .�j
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