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Date: Permit Number:
• . __... _. . . . Building. Permit Application
Planning and Development Services
Building and Code Regulation Division
2300 Virginia Avenue,Fort Pierce Ft.34982 &,000'Phone: (772)462-1553 Fax:(772)462-1578 Commercial Residential.
PERMIT APPLICATION FOR: I ��
Address:
Le al Description. 57 4
ori 4 0 -8.5
Property Tax ID#: 3ya 4J-- S00 001AI, 000 ,8 _ Lot No.
Site Plan Name: Block No:..
Project Name:
Setbacks Front Back: Right Side: Left Side;
O� OL
Additional work to be performed under MR permit-c ecIIN11at appy:
_Mechanical _Gas Tank. _Gas Piping _Shutters _Windows/Doors
VElectric. _Plumbing _Sprinklers _Generator _Roof
Total Sq. Ft of Construction: Sq. Ft.of First Floor:
Cost of Construction:$ �Qt'J` ® Utilities: _Sewer _-Septic Building Height:
.Nam nd Name:
Addre s: Company: ./
City: State Address: gy-7
Zip Code: . 4f.6 2 Fax:', -310•Qr-?A city:,A&j - f..cState:y 7�
Phone No.'7u- 040. A"9 Zip Code:% f, Jy, ' Fax: V4 :7 7
E-Mail: C�scwa�nQ. CAA$ Dha Phone No. J-/G/-a?7 77
Fill in fee simple Title Holder on next page(if different E-Mail:M j'kta Dnidk -.21.e•C.Y 1 Com. 691A
from the Owner listed above) State or County License:
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
DESIGNER/ENGINEER: Not Applicable {MORTGAGE COMPANY:. Not Applicable
Name: Name:
Address: Address.
City: State: City: State.
Zip: Phone• Zip:, Phone!'
FEE SIMPLE TITLE HOLD R: __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.
certify that no.Work or.instailatioii_ties 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 conflictIwith any applicable Home OwnersAssociation rules,bylaws or and.covenants that may restrict or prohibit such
structure.Please consult with your Home Owners Aswclation arid.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 fallowing building permit applications are exempt from:undergoing a`fuii.concurrericy 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. u intend to obtain financing,consult with lender or an attorney before
comm i work or c rdin our Notice of Commencement.
Al A
V1gr1dtVr5 of Ow.erjAgen essee- Sifnature of Contract icense Holder
STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF {��>`� �> y _ . COUNTY OF
The forgoing instrument .was acknowledged t1b:
ore me The forgoing.instrument was acknowledged before me
this day ofC ' Y ���j ails _clay of
(Name of person acknowledging) (Name of person acknowledging)
(Signature a Public-Sta of Florida (Signature Notary Public- tate of Florida)
P 9l/ =A to
Personally Known OR Proc�tfat� Personally Known OR Produ6�i �j1
tc asp s��' T e of Identilrcation Prodi . U9�s see> '
Type of idehtincatian Produced. Yp. owv\ e
suc \QrG?5� . . 'oty9��9..,.
Commission No. aea (Seal) Commission No. * ° e° .. (Seal).. . _r
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REVIEWS FRONT ZONING SUPERVISOR PLANS' VEGETATION`- SEA TURTLE ' MANGROVE
COUNTER REVIEWREVIEW REVIEW REVIEW REVIEW_. REVIEW
DATE
RECEIVED
DATE v
COMPLETED •
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