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Legal Description:
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Site Plan Name: Block No.
Project Name:
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Total Sq. Ft of construction: Sq,Ft.of First Floor
Cost of Construction: Utilities: _Sewer _Septic Building Height:
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Phone No.
E-Mail: jotoLjr
State or Countv License: •
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DESIGNER/ENGINEER: Not Applicable mORTGAGE COMPANY: Not Applicable
Dame: Name:
Address: Address-
City. State: City: State:
Zip: Phone: Zip: ,Phond,
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 Nome Owners Association rules,bylaws or and covenants that may restrict or prohibit such
structure.Please consult with your Horne 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.Ducie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review:room additions,
accessory structures,swimming pools,fences,wells,signs,screen rooms and accessary uses to another non-residential use
WARNING TO OWNER:Your failuire to Record a Notice of Commencement may result irn 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 your Notice-olf Commencement.
Signature of Owner/Agent/Lessee Signature of Contractor/License Molder
STATE OF FLORIDA STA'L'E OF FLORIDA
COUNTY OF 7 L_o c l'g COU loy CIS
The forgoing instrument was acknowledged before me The forgoing Instrument vitas acknowledged before me
this t� day af..__SJutn.�. Zt7_},�S by this- �5 day of .20 by
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_ p o r f Ig. In M orl5 .'u-r3 lis0 .,�
(Mame of person acknowledging) (Nome of person acknowledging)
(Signature of Notary Public Sta of rlorida) (Signature of Notary Public State of orida)
Personally Known OR Produced Identification Personally Known V/. . OR Produced Identification
Type of Identification Produced ,;Y Pup, llS[rMam Sy Type of identification Produced - —
r `t� MyCOMMMIONJ:E858
Commission No. C S 94h * al) EkF1A>S:I>pri34,2017 Commission No_ I}
EXPIRES;April d,2134
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEATURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DATE
RECEiVED
DATE
COMPLETED
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