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All APPLICABLE IN O M STiBCOMPLETED FOR APPLICATION TO BE ACCEPTED �f
Date: Permit Number: 6
_ 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:
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Address: I:?: o q S rT i2j-679ti5' `
Legal Description:
Property Tax ID#: Lot No.
Site Plan Name: Block No.
Project Name:
Setbacks Front Back: Right Side: Left Side:
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Additional worK to be pertormed under this 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: $ 912-20— Utilities: _Sewer _Septic Building Height:
R `t" tta Y� r6i �,'' ✓ s '
OWER/iLESS' E rk ; CONTRACTOR s ,iilr�
Name. ..- Name: r/
Address .,� a: . 2` Company:
City,"' "yf 7�r State: l Address:
ZipfCode: -3 Fax: City: /?S Z State:
Phone No. Tt 9— def �f Zip Code: 3V.5�573 Fax:
E-Mail: Phone No 171 Z —`/3-!
Fill in fee simple Title Holder on next page(if different E-Mail
from the Owner listed above) State or County License GA C
If value of construction is 2500 or more,a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION L 0 LAW hNFORMATIDN:
DESIGNER/ENGINEER: _ Not Applicable MORTGAGE COMPANY: _`Nbt 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 fullconcurrency 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 of O er Lessee Co tactor as Agent for Owner Signature of Contra o cense Holder
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STATE OF FLORIDA STATE OF FLORIDA
COUNTY OF :sa a/T L JC r c COUNTY OF
The forgoing instrument was acknowledged before me The forgoing instrument was acknowledged before me
this_L�L day of 20 L e by this ) Y day of —?-1 ,c)& v 201 C by
(Name of person ac nowledging) (Name of person acknowledging)
(Signature of Notar, ic-State of Florida) (Signature of No y Public-State of Florida)
Personally Known l/ OR Produced Identification Personally Known I/ OR Produced Identification
Type of Identification Type of Identification
Produced Produced Tv 1
�.�`�'a"r'ar;�•,� JOSE FRESNILLO .il'N1YP��•�� OSE1�RESNILLO
Commission No. .'r° ���•_ NotOF 011c-State of Florida Commission No. * +� Notaryr�[��-State of Florida
•. •• Commission#FF 184850 •+ +•= Commisslon FF 184850
;59 .c`%° M C ;? oma;My Comm-Expires ner 99 gol
Bonded throw National Notary Assn. °"� ``'��, Bonded throng National Notary Assn.
REVIEWS FRO' 'ZOTVINO- *' - PLANS VEGETATIO A7RMnE'
COUNTER REVIEW REVIEW REVIEW REVIEW REVIEW REVIEW
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