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,PP'LICABLE INFFO LI� MPL�D FOR APPLICATION'TO BE ACCEPTED
Date: Permit Number.
Building permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Port Pierce FL 34982
Phone:(772)462-1553 Fax:(772)462-1578 Commercial Residential
PERMIT APPLICATION FOR:
Address: rlP�
Legal Description.
Property Tax 1D ?a 'Za Aqq"'7 Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front__ Bank: Right Side: Left Side: -_
�Yt
"1.7,,--aw.-W-ork-tobe.l�e-ffo-rmed
un er t is perms -c ec a a apP y:
—Mechanical
Cas Tank Gas Piping Shutters Windows/Doors
Electric Plumbing Sprinklers Generator Roof
Total Sq,Ft of Construction: Sq.Pt.of First Floor:
Cost of Construction:$ Utilities: Sewer Septic Building height:
Name Name: C'.krtts .$_ _4Y►Y►tpCt �
Address: Company: .us-r�w A.r
City: � , � ,1.,�D State:- Address: ICD i S `Ur` 1 r
Zip Code:" i,?4}'2' Fax: City: YsP�T ST i.1tC tc- _ State:��.,
Phone No, 3, 74 3Zip Code: 34 55 Fax. 77� 335 1 16�
E-Mail: Phone No. 77� 33,5 -'393 �
Fill in fee simple Tilde Holder on next page(if different E-Mail: _ _ Cu AA1r 9 TS a9. ,o?-r&M
from the Owner listed above) State or County License: CA C 0 5 1)?1 D ' S�ztz'
If value of consftucdon is,Zs96or more,a RECORDED Notice of Commencement is required.
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DESiGNERANGINEER: 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 Count makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which is in con ict with an 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 Suild'W 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 failuite 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 of Owner/Agent/Lessee Signature of Contractor/license Holder ^ ,
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF S T L v c Ir-- COUNTY OF-
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this day of - 201S by this- day of _ � 20�_IZ by
OUrfiS m otiS lrtEi�TiS /'r7
(Name of person acknowledging
(Name of person acknowledging)
(signature of Notary PubZlic- a60&fklo�rlda (Signature of Notary Public-State of rida}
Personally Known ✓ OR Produced identification Personally Known OR Produced identification
Type of identification Produced ,Ay pro,, gt data Type of identification Produced
Commission No. al}YF. MMIO #F 2017 Commission No. ��ya�u �+ 'f fig•
�� 8at�1'rdruBudOyB * 1 �'�610NtEE
IRDS:Ape7 4,201
REVIEWS FRONT ZONING SUPERVISOR PLANS VEGETATION SEA TURTLE MANGROVE
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
DAVE
RECEIVED
DATE
COMPLETED
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